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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/compendiumofpracOOgrub 


A    COMPENDIUM 


OF 


PRACTICAL   MEDICINE 


FOR   THE  USE  OF 


Students  and  Practitioners  of  Medicine 


BY 


WILLIS  WEBSTER  GRUBE,  A.  M.,  M.  D., 

Professor  of  Physiology  and  of  Clinical  Medicine  in  the  Toledo  Medical  College;    Visiting 
Physician  to  the  Toledo   Hospital ;    Physician  to  the  Toledo  Medical  College  Dis- 
pensary for  the  Relief  of  the  Out-door  Poor ;  Member  of  the  American  Medi- 
cal Association ;    Member  of   the  Tri-State   Medical  Association ; 
Member  of   the  Toledo  Medical  Association,  etc.,  etc. 


TOLEDO,  OHIO: 

The  Hadley  Publishing  Company. 

1897. 


GIFT 


COPYRIGHTED 


W.    W.    GRUBE, 


19~. 


PREFACE. 

Ill  presenting  this  volume  to  the  medical  profession,  it  may 
not  be  improper  to  state  the  circumstances  which  led  to  the 
undertaking,  and  the  design  which  it  is  intended  to  accomplish. 

The  frequent  requests  on  the  part  of  medical  students  whom 
it  has  been  my  pleasure  to  instruct  during  the  past  few  years,  to 
prepare  a  compendium  of  practical  medicine  which  shall  aid 
them  in  acquiring  established  facts,  is  the  only  apology  I  have  to 
offer  for  its  appearance. 

This  work  is  designed  to  present  the  leading  facts  and  prin- 
ciples of  medicine,  in  a  brief,  clear  and  concise  manner,  so  that 
they  may  be  readily  comprehended.  My  chief  aim  has  been  to 
prepare  a  book  of  an  essentially  practical  character — one  neither 
so  meager  in  detail  as  to  be  next  to  useless,  nor  so  overladen  with 
unnecessary  matter  as  to  be  unwieldy  and  lacking  in  precise 
knowledge.  The  ever- recurring  wants  and  requirements  of  the 
medical  student  and  practitioner  have  been  kept  constantly  in 
view. 

In  the  preparation  of  the  work,  the  author  has  carefully 
examined  all  the  best  material  at  his  command  and  freely  used 
it;  the  special  object  being  to  have  it  abreast  of  the  present 
knowledge  on  the  subjects  treated  as  far  as  such  is  possible  in  a 
work  of  this  kind;  and  every  effort  has  been  made  to  give  it  all 
the  freshness  of  interest  and  clearness  of  expression  possible. 

The  discussion  or  even  mention  of  mere  theories  has  been 
purposely  avoided,  for  experience  has  taught  us  that  such  dis 
cussions  serve  only  to  confuse  and  discourage.  In  issuing  a 
volume  of  this  character,  it  is  perhaps  but  just  to  say  that  of 
course  it  cannot  and  is  not  intended  to  replace  the  classical 
works.  For  more  minute  information,  extended  description  and 
elucidation  and  other  minutiae  for  which  the  work  of  reference 
is  consulted,  recourse  must  be  had  to  more  extended  text -books 


PREFACE. 


and  similar  sources  of  information.  Nevertheless,  it  is  confi- 
dently believed  that  the  present  volume  meets  a  distinct  and  im- 
perative need  of  the  medical  student  and  general  practitioner, 
conveying  in  condensed  and  convenient  form  concise  and  practi- 
cal information  for  which  they  are  liable  to  have  continual  use. 

In  my  endeavor  to  keep  this  book  within  reasonable  limits, 
I  have  touched  but  lightly  upon  the  pathology  of  disease,  except 
in  those  cases  in  which  such  knowledge  would  aid  in  the  treat- 
ment, and  have  purposely  omitted  all  unimportant  details.  Not- 
withstanding my  utmost  efforts  at  condensation,  the  work  has 
grown  beyond  the  contemplated  size. 

Much  of  the  matter  embraced  in  a  work  of  this  kind  is 
the  common  property  of  the  medical  profession,  and  credit  has 
been  given  for  facts  or  opinions  by  merely  inclosing  the  name  of 
the  author  in  parenthesis.  If  I  have  failed  to  give  credit  in  any 
case,  it  is  unintentional. 

I  would  gladly  acknowledge  my  indebtedness  to  Prof.  J.  H. 
Pooley,  M.  D.,  of  Toledo,  for  the  preparation  of  Chapter  IV., 
on  "First  Help  in  Surgical  Emergencies,"  and  to  Prof.  W.  J. 
Gillette,  M.  D.,  of  Toledo,  for  the  preparation  of  Chapter  III., 
on  "Medical  Diseases  of  Women." 

I  also  acknowledge  my  indebtedness  to  the  standard  works 
of  Bartholow,  Loomis,  Flint,  DaCosta,  J.  L.  Smith,  Skene, 
Thomas,  Pozzi,  Anderson,  Fox,  Noyes,  Milton,  Keyes,  Bosworth, 
Bryant,  Lusk,  Habershon,  Starr,  Hammond,  and  many  others. 

To  the  many  kind  friends  who  have  encouraged  me  to  un- 
dertake this  work,  I  return  my  warmest  thanks. 

W.  W.  GRUBE,  M.  D., 

1502  Collingwood  Ave., 

Toledo,  Ohio. 
March,  1897. 


CONTENTS  AND  GENERAL  INDEX. 


Examination  of  the  patient.     17.     History  of.     17.     Present  condition.    17. 
Position  of  body.     18.     General  aspect.     18. 

PAGE. 

The  Skin  in  Disease 19 

The  Pulse  in  Disease 19 

The  Tongue  in  Disease 24 

The  Temperature  in  Disease 27 

Chronic  Fever 30 

Clinical  Index 649 

Fee  Bill 664 


Abortion 32 

Abscess 37 

Acidity 40 

Acne  41 

Acne  Rosacea 45 

Addison's  Disease 46 

A  fter-pains 47 

Agalactia 48 

Ague  (See  Intermittent  Fever)...  48 

Ague-cake 48 

Albinism 49 

Albuminuria 48 

Alcoholism  50 

Alopecia 51 

Amaurosis 53 

Amblyopia 53 

Amenorrhoea 610,  53 

Anaemia 56 

Anaesthesia 62 

Anaesthetics 635 

Anasarca 60 

A  nchy  losis 62 

Aneurism 58 

Angina  Pectoris 60 

Anthrax 61 

Aphasia 64 

Aphonia 70 

Apoplexy 64 

Apthae 63 

Appendicitis  66 

Ascaris  Lumbricoides 70 

Ascites 66 

Asphyxia 72 


Asthenia 69 

Asthma.... 67 

Atheroma 72 

Backache  73 

Balanitis 73 

Baldness 73 

Basedow's  Disease 73 

Bed-sore 73 

Biliousness 74 

Bites 75 

Bladder  Diseases 76 

Blepharitis 76 

Bloody-flux 76 

Blood-poisoning  77 

Boils 76 

Borborygmus 78 

Breasts.  Inflammation  ol 78 

Breath,  Foul 77 

Bright's  Disease 83 

Bronchitis 79 

Bronchocele 78 

Bubo 84 

Bubonocele 78 

Bunions 86 

Burns  and  Scalds 625,  87 

Calcificaiion 141 

Calculi 89 

Cancer 95 

Cancrum  Oris 132 

Carbuncle 100 

Cardialgia 133 

Caries 99 

Catalepsy 133 


XII. 


GENERAL    index. 


Catarrh,  Nasal  and  Chronic  Gas- 
tric   100 

Cephalalgia 134 

Cerebro-Spinal  Meningitis 134 

Chancre 109 

Chancroid 110 

Chicken-pox 135 

Chilblains 112 

Chiragra 220 

Chloasma 141 

Chlorosis 113 

Cholera  Infantum 116 

Cholera  Morbus 115 

Chordee....,.,,,, 118 

Chorea 120 

Circumcision 135 

Cirrhosis  of  Liver 143 

Cold,  Exposure  to    626 

Cold  Feet 137 

Colic 121 

Coma 136 

Comedones 140 

Condylomata 123 

Conjunctivitis  124 

Constipation 125 

Convulsions 127 

Copper-nose 45 

Coryza 128 

Cough 137 

Cramps 142 

Croup , 128 

Cystitis 131 

Cysts 140 

Dactylitis 164 

Dandruff 164 

Debility 143 

Delirium 144 

Delirium  Tremens 145 

Derbyshire  Neck 164 

Diabetes  Insipidus 146 

Diabetes  Mellitus 147 

Diarrhoea 149 

Dislocations 627 

Dyphtheria 151 

Dypsomania 154 

Dirt-eating 155 

Dropsy 155 

Drowning 627-164 

Dysentery 157 

Dysmenorrhea 613,  159 

Dyspepsia 161 

Earache 164 

Eclampsia 183 


Eczema 165 

Embolism 184 

Emissions  169 

Emphysema 172 

Empyema 173 

Endocarditis    175 

Endometritis 620,  186 

Endosteitis , 392 

Enteralgia 190 

Enteritis 176 

Enuresis  184 

Ephidrosis 190 

Epididjrmitis 187 

Epilepsy 178 

Epispadias 189 

Epistaxis 180 

Epithelioma 189 

Eructations  (Offensive) 189 

Erysipelas 181 

Erythema 183 

Exophthalmic  Goitre 213 

Faintings 199 

Falling  Sickness 199 

Fatigue 200 

Felon  199 

Fetor  of  Axilla  and  Feet 191 

Fevers  (in  general) 191 

Fissure  of  Anus 192 

Fissure  of  Nipple 194 

Fistula 195 

Fits 199 

Flatulence 196 

Flooding 199 

Flushing  Heats 200 

Foreign  Bodies  in  Eye,  Ear,  and 

Nose 628 

Fractures 267-201 

Freckles,  Sunburn  and  Tan 197 

Frostbite 198 

Furuncle 199 

Galactorrhea 202 

Gail-Stones ' 203 

Gangrene 203 

Gas,  Asphyxiation  from 629 

Gastralgia 206 

Gastric  Ulcer 207 

Gastritis  (Toxic) 223 

Giddiness 226 

Gingivitis 224 

Glanders 226 

Glands,  Enlarged  Lymphatics....  210 

Glaucoma 224 

Gleet ,„ 211 


GENERAL    INDEX. 


XIII. 


PAGE. 

Glycosuria 227 

Goitre 213 

Gonagra 227 

Gonorrhoea 215 

Gout '  220 

Granulating  Lids 226 

Gravel 226 

Graves'  Disease 226 

Green  Sickness 226 

Grocers'  Itch 165 

Gumma 226 

Gums  (Spongy) 223 

Hematocele 259 

Hemidrosis 260 

Hemoptysis 230 

Hemorrhage 630,  239 

Hernatemesis 227 

Hematuria 228 

Hay  Fever 232 

Headache 234 

Head-injury  262 

Heart-burn 237 

Heart  Diseases 238 

Heat  Stroke 255 

Hectic  Fever 256 

Hemicrania 237 

Hemiplegia 237 

Hemorrhoids 242 

Hepatitis 244 

Hernia 630,263 

Herpes 245 

Hiccough 247 

Hives 257 

Hoarseness 257 

Hodgkin's  Disease 261 

Hordeolum 258 

Horns 262 

House-maid's  Knee 258 

Hydrocele 259 

Hydrocephalus 248 

Hydronephrosis 272 

Hydrophobia 274 

Hydrothorax 249 

Hymen-Irnperforate 261 

Hyperidrosis 260 

Hypochondriasis 250 

Hypospadia 261 

Hysteria 252 

Icterus 296 

Icthyosis 275 

Impetigo  276 

Impotence 279 

Incontinence  of  Urine 282 


PAGE. 

Indigestion  277 

Inflammation 277 

Influenza 282 

In-growing  Toe-nail 284 

Injuries  to  Brain 631 

Insolation 296 

Insomnia 284 

Intermittent  Fever 286 

Intertrigo 286 

Intestinal  Catarrh 287 

Intestinal  Obstruction 287 

Intussusception 287 

Iodism 296 

Iritis 294 

Irritability 297 

Itch ,....  287 

Itching 297 

Jaundice 297 

Keratitis 299 

Kidney  Diseases 300 

King's"  Evil 300 

Knee-jerk 300 

Labor 301 

Lactation  (Excessive.) 319 

Laryngismus  Stridulus 302 

Laryngitis  303 

Lead  Colic 320 

Lead-poisoning 305 

Lentigo 320 

Leprosy 307 

Leucocythemia 308 

Leucoderma 320 

Leucorrhoea 616,  311 

Lice 313 

Lichen 314 

Lipoma 319 

Lockjaw 319 

Locomotor    Ataxia 315 

Lumbago 318 

Lupus , 31S 

Lymphadenoma 310 

Malarial  Fevers 320 

Mania 332 

Mania,  a  potu 354 

Marasmus 333 

Mastitis 332 

Masturbation 354 

Measles 333 

Melancholia 336 

Meniere's  Disease 357 

Meningitis 337 

Menorrhagia 350 

Metritis 620 


XIV 


GENERAL    IXDEX. 


Metrorrhagia 350 

Migraine 351 

Milium 357 

Milk-leg 357 

Miscarriage    357 

Mitral  Disease 351 

Moles 357 

Morbus   Coxarius 358 

Morning  Sickness 351 

Mother's  Mark 357 

Mumps 352 

Muscular  Rheumatism 358 

Myalgia  354 

Myelitis 343 

Nsevus 359 

Nausea 364 

Necrosis 360 

Nephritis 360 

Nettlerash 360 

Neuralgia 360 

Neurasthenia 366 

Neuritis 364 

Nightmare 365 

Night  Screaming 365 

Nipple  (Sore) 363 

Nymphomania 363 

Obesity 366 

(Eclema 36/ 

(Esophageal  Obstruction 379 

Onanism 376 

Onychia  Maligna.. 36/ 

Opacities  in  Eye 377 

Ophthalmia 368 

Opium  Habit 369 

Orchitis 371 

Ostitis 392 

Otalgia  374 

Otitis 373 

Overwork 378 

Oxaluria 374 

Oxyuris-  Vermicularis . .  376 

Ozena 375 

Painter's  Colic... 320 

Palpitation 380 

Paralysis  383 

Paralysis  Agitans 473 

Paraphimosis 468 

Paraplegia 386 

Paresis 383 

Paronychia 199 

Parotitis 352 

Pediculi . 387 

Pemphigus 387 


PAGE. 

Pericarditis 388 

Periostitis 392 

Peritonitis 394 

Pertussis  400 

Phagedena 402 

Pharyngitis 403 

Phimosis 468 

Phlegmasia  Alba  Dolens 404 

Phthisis 406" 

Phthisis  (Fibroid) 431 

Pica  and  Malacia 472 

Piles  242 

Pityriasis 164 

Pleurisy 433 

Pneumonia  (Lobar.) 440 

Pneumonia  (Lobular.)    452 

Podagra 220 

Poisoning ' 632 

Pollution.. 170 

Polyphagia 473 

Polyuria 146 

Posterior  Spinal  Sclerosis 315 

Priapism 455 

Prickly  Heat 456 

Prostatitis 456 

Prostatorrhcea 458 

Prurigo 459 

Pruritis 460 

Psoriasis 461 

Pterygium 470 

Ptyalism 493 

Puerperal  Fever 463 

Purpura 465 

Pyaemia 466 

Pyelitis  470 

Pyonephrosis 470 

Pyrosis " 467 

Quinsy 567 

Rabies 274 

Rachitis 475 

Ranula 486 

Rashes  (Medicinal) 489 

Relapsing  Fever 490 

Relaxed  Uvula 488 

Remittent  Fever 329 

Renal  Calculi 92 

Restlessness... 489 

Retention  of  Urine 486 

Rheumatism 478 

Rheumatism  (Chronic  Articular)  483 

Rheumatoid  Arthritis 485 

Ringworm 565 

Roseola 488 


GENERAL    INDEX. 


XV 


PAGE. 

Rubeola 333 

St.  Vitus   Dance 120 

Salivation  493 

Salt  Rheum 165 

Satyriasis 494 

Scabies 494 

Scalds 87 

Scarlatina 495 

Sciatica 361 

Scorbutus 507 

Sclerosis  of  Brain 501 

Sclerosis,  Cerebro-spinal 502 

Scrofula 504 

Scurvy 507 

Sea  Sickness 508 

Seminal  Emissions 169 

Septicaemia 510 

Shingles 246 

Shock 633,539 

Sick  Headache 235 

Singultus 247 

Sleeplessness 284 

Small  Pox 594 

Sneezing 537 

Somnambulism. 537 

Sore-feet 537 

Sores 585 

Spermatorrhoea 511 

Spina  Bifida 515 

Spinal  Irritation 536 

Sprains 634,518 

St.  Anthony's  Fire 181 

Stenosis  of  (Esophagus 379 

Stings 538 

St.  Job's  Disease 542 

Strangury 514 

Stricture 520 

Struma 504 

Stye  (See  Hordeolum.) 514 

Sudamina ■__ 539 

Summer  Complaint 116 

SunStroke 255 

Suppression  of  Urine 540 

Sweating 190 

Syncope 199 

Synovitis 541 

Syphilis 542 


Tape-worms 560 

Tetanus 562 

Tic  Douloureux 360 

Tinea 564 

Tinnitus  Aurium 566 

ThreadWorm 376 

Thrush 564 

Tongue-tie 572 

Tonsilitis 567 

Tooth  ache 569 

Torticollis.., 354 

Trachoma 572 

Trichinosis .__ 571 

Trismus 562 

Tuberculosis  ,' Acute  Miliary.)  . .  432 

Tympanites 570 

Typhoid  Fever 572 

Typhus  Fever 583 

Ulcers  and  Sores 585 

Uraemia 586 

Urethritis 215 

Urticaria 587 

Vaccination 596 

Vaginismus 588 

Vaginitis 618 

Valvular  Diseases 596 

Varicella 593 

Varicocele 590 

Varicose  Veins 590 

Variola 594 

Varoiloid 595 

Vertigo ' 590 

Vitiligo 320 

Vomiting 592 

Vulvitis 589 

Wakefulness 284 

Warts 607 

Water  Brash 467 

Wens 141 

Whites 311,  616 

Whitlow . 199 

Whooping  Cough 400 

Worms 376.  560 

Wounds  (poisoned) 632 

Wrist-drop 305 

Wry-neck 354 

Yellow  Fever 60S 


CHAPTER  I. 
THE  EXAMINATION  OF  PATIENTS. 


To  elicit  the  facts  of  a  case  by  careful  examination  is  the 
first  requisite  for  diagnosis.  There  are  two  methods  of  exami- 
nation— the  synthetical  and  the  analytical.  The  synthetical 
method  is  the  more  scientific,  but  is  too  full,  and  calls  for  too 
much  labor,  to  meet  the  requirements  of  ordinary  professional  life. 
It  is  the  best  where  the  symptoms  are  obscure  and  ill  defined. 
It  consists  in  getting  the  family  history  and  the  history  anteced- 
ent to  the  present  disease,  before  the  present  condition  is  ex- 
plored. 

In  the  analytical  method  the  present  condition  is  first 
ascertained. 

Da  Costa  uses  the  following  plan  of  examination:  1.  Date 
of  examination.  2.  Name.  3.  Age.  4.  Color.  5.  Place  of 
Birth.  6.  Present  abode.  7.  Occupation.  8.  In  female,  whether 
married  or  not,  number  of  children,  and  date  of  last  confinement. 

History — I.  History  antecedent  to  present  disease:  (1) 
Constitution  and  general  health.  (2)  Hereditary  predisposition 
(family  history.)  (3)  Previous  diseases  or  injuries.  (4) 
Habits  and  mode  of  life.  (5)  Hygenic  influences  to  which  ex- 
posed. 

II.  History  of  present  disease:  1  Its  supposed  exciting 
cause.  2  Date  of  seizure.  3  Mode  of  invasion.  4  Subsequent 
symptoms  in  order  of  succession.     5  Previous  treatment. 

Present  Condition  of  Patient.  I.  General  symptoms:  1. 
Position,  in  bed — mode  of  lying — out  of  bed — movements.  2. 
Aspect,  of  body — of  countenance.     3.  Skin.    4.  Pulse.     5.  Tern- 


18  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

perature.  6.  Respiration.  7.  Tongue.  8.  Appetite,  thirst,  and 
condition  of  bowels.  9.  General  state  of  urinary  secretion.  10. 
Sensations  of  the  patient  as  to  pain,  etc. 

II.  Examination  of  special  regions.  Diagnosis.  Treat- 
ment. 

Position  of  the  Body.  If  the  patient  is  in  bed,  note  how 
he  lies;  if  out  of  bed,  how  he  walks.  If  a  healthy  person  be 
suddenly  confined  to  his  bed,  the  inference  is  that  he  will  have 
an  acute  and  severe  disease.  If  the  patient  lies  fixed  upon 
one  side,  it  shows,  as  a  rule  that  the  action  of  the  lung  of  this 
side  is  impaired.  The  patient  may  be  in  bed  but  unable  to 
lie  down  on  account  of  distress  in  breathing.  This  dyspnoea 
is  encountered  especially  in  diseases  of  the  heart,  or  where  fluid 
is  effused  into  the  air  cells  or  into  both  pleural  cavities. 

In  some  diseases  of  the  brain  the  gait  is  staggering.  In 
one-sided  palsy  the  movements  are  uncertain. 

General  Aspect. — Expression  of  Countenance.  The  eye 
notices  whether  the  body  is  bulky  or  wasted.  If  the  bulky 
aspect  is  due  to  air  in  the  tissues,  they  crepitate  under  the 
finger;  if  too  fluid,  the  skin  pits  under  pressure. 

Emaciation  is  a  more  frequent  symptom  than  augmentation. 
Jt  may  take  place  rapidly  or  gradually.  Among  the  counte- 
nances most  frequently  met  with  is  that  of  apathy  and  stupor. 
The  eye  is  dull  and  listless;  the  face  pale  or  flushed  with  fever. 
This  look  is  common  in  fevers  of  a  low  type  and  is  combined 
with  dark  material  on  the  lips,  gums  and  teeth. 

Unnatural  fulness  and  congestion  of  the  features  are  some- 
times observed  in  enlargements  of  the  heart,  and  oftener  still  in 
habitual  drunkards. 

The  same  aspect  is  seen  in  apoplexy  and  in  typhus  fever. 
A  pinched  expression  is  found  when  there  is  intense  anxiety  or 
pain.  The  Hippocratic  countenance  denotes  the  moribund  state. 
It  is  characterized  by  marked  pallor  with  more  or  less  lividity, 
jnnching  of  the  nostrils,  sinking  of  the  eyes,  hollowness  of  the 
temples,  coldness  and  transparency  of  the  ears,  dropping  of  the 
lower  jaw. 

The  face  of  shock,  with  its  great  pallor,  its  anxious  or 
frightened  look,  is  seen  after  severe  injuries  and  oj)erations. 


EXAMINATION    OF    PATIENT.  19 

A  dusky  flush  on  the  face,  if  associated  with  rapid  breath- 
ing, is  almost  a  certain  indication  of  inflammation  of  the  lung. 

Pivffiness  of  the  eyelids  in  a  pallid  person  is  very  apt  to  be 
expressive  of  Bright's  disease. 

There  is  the  straw-colored,  anaemic  hue  of  malignant  dis- 
ease; the  jaundice,  melancholy  look  of  an  hepatic  affection- 
Skin. — Coldness  of  the  skin  indicates  a  weakened  capillary 
circulation.  Protracted  coldness,  whether  attended  with  dryness 
or  with  clamminess,  is  of  evil  augury.  The  skin  is  pale  when- 
ever the  blood  is  poor  and  watery.  In  wasting  and  prostrating 
ailments  the  skin  feels  very  relaxed  and  soft.  The  skin  may  be 
dry,  moist,  or  profusely  wet  and  sodden. 

In  most  fevers  with  high  temperature  the  skin  is  hot.  Now, 
if  we  make  the  patient's  skin  moist,  we  promote  his  comfort  and 
well-being.  Small,  often-repeated  doses  of  tincture  of  aconite 
or  tartar  emetic  will  induce  perspiration. 

In  many  cases  of  diabetes  and  Bright's  disease,  it  is  very 
difficult  to  make  the  very  dry  skin  perspire. 

The  two  chief  causes  of  sweating  are  weakness,  and  a  fall 
in  a  febrile  temperature,  two  causes  often  combined  in  the  same 
person  in  exhausting  febrile  disease,  as  in  phthisis. 

In  exhausting  diseases,  sleep  may  produce  sweating.  Pro- 
fuse sweating  occurs  during  convalescence  from  scarlet  fever. 

With  the  exception  of  rheumatic  fever,  profuse  sweating  at 
the  commencement  of  an  acute  febrile  disease,  when  the  temper- 
ature remains  high,  indicates  great  weakness.  Duskiness  of  the 
face,  ears  and  under  the  nails  shows  weakened  heart  action. 

Pulse. — The  pulse  is  an  accurate  index  of  the  condition  of 
the  heart,  and  is  therefore  the  most  valuable  guide  in  disease. 

The  importance  of  the  pulse  is  manifest  when  we  consider 
that  disease  kills  by  arresting  the  heart.  Whilst  the  heart  beats 
there  is  life  and  hope.  In  many  instances,  the  pulse  gives  the 
first  signs  of  danger,  as  in  the  case  of  pneumonia,  in  which  dis- 
ease so  long  as  the  pulse  continues  good  we  have  fair  hopes  of 
our  patient.  In  other  instances  the  nervous  system  first  gives 
way,  as  shown  by  sleeplessness  and  delirium,  and  this  depresses 
and  weakens  the  heart. 


20  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

In  any  case  it  is  the  ultimate  effect  of  the  disease  on  the 
heart  that  destroys  life. 

The  pulse -beats  may  be  frequent  or  infrequent,  slow  or 
quick;  small  or  large;  compressible  or  incompressible;  regular 
or  irregular;  or  intermittent. 

By  the  frequency  of  the  pulse  we  mean  the  number  of  beats- 
in  a  given  time. 

In  a  quick  pulse  each  beat  occupies  less  than  the  usual 
time,  that  is,  each  wave  is  of  short  duration  relatively  to  the 
pause  between  the  waves. 

When  the  volume  of  the  pulse  is  greater  than  usual,  it  is- 
said  to  be  large;  or  the  volume  may  be  less  than  usual,  when  it 
is  said  to  be  small. 

When  the  fingers  can  easily  stop  the  pulse  it  is   said  to  be 

compressible;  when  on  the   other  hand,   it  can  be  arrested  only 

with  difficulty  or  not  at  all,  the  pulse  is  said  to  be  incompressible. 

In  an  irregular  pulse,  succeeding  beats  differ  in  length,  force 

and  character. 

In  an  intermittent  pulse  a  beat  is  from  time  to  time  lost. 
The  frequency  of  the  healthy  pulse  varies;  thus,  in  some 
persons  the  normal  pulse  is  100,  in  others  as  low  as  50  a  min- 
ute.    Five  conditions  produce  a  frequent  pulse:  fever,  debility r 
excitement,  hysteria,  and  cardiac  disease. 

In  fevers  the  pulse  is  generally  accelerated  in  proportion  to- 
the  elevation  of  temperature,  more  in  children  than  in  adults. 

When  a  pulse  is  more  frequent  than  the  temperature  will 
explain,  it  indicates  cardiac  weakness.  In  all  febrile  diseases,  a 
pulse  in  adults  over  120  is  serious  and  indicates  cardiac  weak- 
ness; a  pulse  of  130  or  140  indicates  great  danger;  and  with  a 
pulse  at  160  the  patient  almost  always  dies. 

In  rheumatic  fever  a  pulse  of  120  indicates  great  danger. 
In  such  a  case,  the  temperature  is  104°  to  105°  F.,  the  patient 
is  prostrate,  the  tongue  dry,  and  sordes  collect  on  the  lips ;  a, 
case  like  this  often  ends  fatally,  and  when  the  pulse  rises  above 
120,  the  patient  will  pretty  surely  die. 

If .  pericarditis,  a  complication  of  rheumatism,  causes  the 
frequent  pulse,  it  is  of  less  import. 


EXAMINATION    OF    PATIENT.  21 

An  irregular  pulse  from  mitral  disease  may  be  very  frequent, 
120,  130,  or  more,  without  indicating  extreme  danger. 

Sometimes  in  typhoid  fever,  though  the  temperature  is  high, 
"the  pulse  remains  normal  throughout  the  attack,  and  this  shows 
.absence  of  cardiac  weakness. 

In  chronic  diseases  a  frequent  pulse  very  generally  indicates 
-cardiac  weakness.  A  weakened  heart  diminishes  arterial  tension, 
.and  the  pulse  becomes  soft  and  compressible.  If  the  heart  be- 
comes still  more  weak,  the  pulse  becomes  small  as  well  as  quick, 
and  compressible.  Smallness  of  the  pulse,  therefore,  indicates 
still  greater  weakness.  When  the  pulse  is  very  small  it  is  said 
to  be  thready.  The  more  frequent,  the  more  compressible,  the 
smaller  the  pulse,  the  greater  the  cardiac  weakness,  and  the 
greater  the  need  of  cardiac  stimulants. 

The  general  condition  of  the  patient  may  be  good,  but  the 
pulse  is  frequent,  small,  compressible  and  quick,  and  indicates 
danger.  The  pulse  in  some  persons  is  easily  made  frequent  with- 
out this  frequency  indicating  any  danger.  In  some  persons  in 
perfect  health  we  find  a  very  small  and  compressible  pulse.  So 
long  as  the  pulse  remains  good,  we  feel  that  our  patient  is  com- 
paratively safe. 

An  infrequent  pulse  occurs  in  some  cases  of  blood -j)oison- 
ing,  as  in  jaundice,  uraemia,  and  in  these  cases,  the  tempera- 
ture is  often  subnormal.  An  infrequent  pulse  is  met  with, 
sometimes  in  fatty  degeneration  of  the  heart,  and  in  aortic  ob- 
struction, in  irritation  of  the  vagus  or  its  root,  as  in  meningitis, 
cerebral  tumors  or  compression. 

The  size  of  the  pulse  varies  in  disease.  It  is  often  large  at 
the  commencement  of  fever.  The  pulse  is  small  in  inanition, 
owing  to  the  small  quantity  of  blood.  It  is  small,  too,  in  mitral 
obstruction,  and  in  mitral  regurgitant  disease,  and  in  aortic 
stenosis;  also  with  cardiac  debility. 

In  an  intermittent  pulse,  an  occasional  beat  is  missed,  the 
rhythm  being  otherwise  regular.  An  intermittent  pulse  is  very 
different  from  an  irregular  pulse.  Some  persons  have  a  life-long 
intermittent  pulse,  but  ordinarily  it  does  not  occur  till  after 
middle  age.  It  maybe  persistent  or  occasional;  and  when  occa- 
sional only  it  is  often  due  to  an  idiosyncrasy,  and  is  caused  by 


22  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

some  article  of  food,  as  tea,  smoking  or  indigestion.  By  the 
intermission  some  persons  are  made  very  uncomfortable  and 
nervous,  and  get  the  sensation  as  if  the  heart  stopped  or  rolled 
over.     In  most  cases  an  intermittent  heart  is  of  no  significance. 

An  irregular  pulse  is  of  far  more  serious  significance  than 
an  intermittent.  The  pulse  is  irregular,  both  in  force  and  rhythm, 
succeeding  beats  differing  in  length,  force  and  character.  It  is 
generally  due  to  mitral,  and  rarely  occurs  in  other  forms  of  heart 
disease,  though  sometimes  met  with  in  great  cardiac  prostration, 
as  in  an  acute  febrile  illness,  a  few  hours  before  death.  It  occurs, 
too,  in  fatty  degeneration  of  the  heart,  and  in  the  first  and  sec- 
ond stage  of  meningitis.  The  irregular  pulse  indicates  the  need 
of  digitalis.  Whilst  an  irregular  pulse  almost  always  indicates 
mitral  disease,  yet  a  perfectly  regular  pulse  may  accompany 
either  mitral  obstruction  or  regurgitation.  Although  irregu- 
larity from  mitral  disease  is  rare  in  children,  yet  Ringer  has  seen 
aconite,  in  half- drop  doses  repeated  hourly  several  times  pro- 
duce marked  irregularity  of  the  pulse.  An  irregular  pulse  is 
common  in  children  with  tubercular  meningitis,  and  it  is  a  diag- 
nostic guide.  In  some  cases  of  cerebral  disease,  with  Cheyne- 
Stokes  breathing,  the  pulse  is  irregular. 

An  irregular  pulse  may  be  due  to  much  smoking,  to 
venereal  excess,  and  to  tea  drinking.  The  condition  of  the 
blood-vessels  influences  the  pulse. 

Through  the  action  of  the  vaso- motor  nerves  on  the  mus- 
cular coat  of  the  arteries,  the  small  blood-vessels  undergo  relaxa- 
tion or  contraction.  When  the  vessels  are  relaxed  the  blood 
passes  easily  from  the  arteries  to  the  veins,  hence  arterial  tension 
is  slight,  and  the  pulse  is  soft,  large  and  compressible.  This 
pulse  is  met  with  in  the  early  stage  of  some  fevers. 

Arterial  relaxation,  or  low  tension,  produces  a  dicrotic  pulse. 
In  this  pulse  one  of  the  normal  secondary  waves  of  oscillation 
becomes  greatly  exaggerated,  so  that  it  can  be  easily  felt  by  the 
finger.  Indeed,  it  may  be  so  distinct  that  an  inexperienced  per- 
son may  mistake  it  for  the  primary  wave.  Ringer  has  known  a 
nurse  to  make  this  mistake,  and  thus  to  double  the  number  of 
true  pulsations.  A  dicrotic  pulse  always  indicates  marked 
arterial  relaxation,  and  often  coincides  with  cardiac  weakness 


EXAMINATION    OF    PATIENT.  23 

and  is  frequently  met  with  in  typhoid  fever.  When  the  vessels 
are  contracted  the  blood  escapes  with  greater  difficulty  from  the 
arteries  into  the  veins,  and  we  have  the  pulse  of  high  arterial 
tension.  In  this  case  the  artery  is  hard  and  cord-like;  it  can  he 
rolled  under  the  finger  and  is  easily  traced  in  its  course  up  the 
fore-arm.  With  the  vessels  in  this  condition,  the  pulsation  is 
often  so  slight  that  it  might  readily  be  mistaken  for  a  weak  pulse ; 
but  its  incompressibility  prevents  this  error.  In  addition  to  be- 
ing small,  the  pulse  is  slow  and  hard. 

The  following  conditions  give  rise  to  high  arterial  tension: 
1.  Degeneration  of  vessels.  2.  Bright's  disease,  especially  the 
contracted  kidney.  3.  Gout,  jaundice,  lead-poisoning,  ergot  and 
gallic  acid.  4.  Affections  of  the  nervous  system.  5.  The  rigor 
of  fevers. 

High  arterial  tension  and  hypertrophy  of  the  heart,  asso- 
ciated with  an  increased  quantity  of  urine  containing  a  small 
quantity  of  albumen,  enables  us  to  diagnose  the  contracted  form 
of  Bright's  disease. 

During  the  rigor  or  chill  of  fevers  the  arteries  contract,  and 
produce  a  pulse  of  high  arterial  tension,  which  is  frequent,  small, 
hard,  incompressible  and  slow.  When  the  chill  is  over  and  the 
fever  established,  the  arteries  relax,  and  the  pulse  is  large,  full, 
and  not  easily  compressed — bounding,  as  it  is  called. 

In  well-marked  aortic  regurgitation,  the  pulse  is  often  char- 
acteristic. It  is  a  pulse  of  extreme  low  tension.  If  the  radial 
artery  is  at  all  visible  with  the  limb  dependent,  this  visibility 
becomes  much  more  marked  on  raising  the  arm.  In  advanced 
aortic  regurgitation,  the  pulse  gives  to  the  finger  a  sharp,  quick 
stroke.  This  is  the  diagnostic  quality  of  the  pulse.  The  pulse 
feels  as  if  a  small  ball  or  shot  was  puffed  under  the  finger,  and 
is  called  the  shotty  pulse.  Visible  pulsation  of  the  whole 
length  of  the  carotid  to  the  lobe  of  the  ear,  and  of  the  tempera] 
and  perhaps  of  the  facial  artery,  is  far  more  frequently  due  to 
aortic  regurgitation  than  to  high  arterial  tension,  or  to  low  ar- 
terial tension,  or  to  degeneration  of  the  arteries. 

Aortic  regurgitation  is  especially  a  disease  of  middle  or 
advanced  life,  being  due  to  age  and  strain.  In  arterial  degen- 
eration the  arteries  become  elongated  and  tortuous,  easily  visible 


24  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

in  the  brachial  just  above  the  elbow.     The  arteries  feel  hard  and 
corcly,  and  sometimes  calcareous  plates  can  be  felt. 

The  pulse  of  aortic  obstruction  is  slow,  generally  small,  in- 
frequent, and  often  hard.  In  marked  mitral  obstructive  disease, 
the  pulse,  when  not  irregular,  is  small  and  compressible. 

Aneurism  of  the  aorta  often  delays  the  pulse,  and  it  may 
do  this  on  one  side  more  than  on  the  other,  or  on  one  side  alone. 
In  aneurism  of  the  aorta  influencing  the  arteries  of  one  arm 
only,  the  artery  on  this  side  can  be  felt  to  fill  more  slowly 
(Ringer). 

As  the  full  pulse  is  not  always  strong,  neither  is  the  small 
pulse  always  weak  (DaCosta). 

Such  are  the  meanings  attached  to  the  various  characters  of 
the  pulse.  The  appreciation  of  these  different  kinds  of  pulses 
requires  considerable  practice. 

Tongue. — The  tongue  is  a  mirror  which  reflects  the  condition 
of  the  digestive  functions,  the  complexion  of  the  nervous  power 
and  of  the  blood,  and  the  state  of  the  secretions. 

We  examine  the  tongue  in  regard  to  its  movements,  its 
volume,  its  dryness  or  its  humidity,  its  color  and  its  coating. 

The  movements  of  the  tongue  are  impeded  and  tremulous 
in  exhausted  states  of  the  system.  It  is  protruded  slowly  and 
with  difficulty  in  fevers  of  a  low  type.  In  hemiplegia  one  side 
is  crippled,  and  the  tongue  turns  toward  one  of  the  corners  of 
the  mouth. 

The  volume  of  the  tongue  is  changed  by  its  own  diseases 
Yet  a  broad  and  flabby  tongue,  on  the  sides  of  which  the  teeth 
leave  their  marks,  is  sometimes  found  in  chronic  ailments  of  the 
digestive  organs,  and  as  a  result  of  the  action  of  mercury  and  of 
certain  poisons.  It  is  observed  in  some  diseases  of  the  brain 
and  heart,  and  in  typhus  and  scurvy. 

Dryness  of  the  tongue  indicates  deficient  salivary  secretion. 
The  tongue  is  dry  in  acute  visceral  inflammations,  in  the  exan- 
themata, and  in  typhoid  fever.  If  the  tongue  be  very  dry,  of  a 
dark  color,  glazy,  or  furred  or  fissured,  it  denotes  depraved 
-blood.  A  fissured  tongue  may  occur  in  chronic  affections  of  the 
liver  and  intestines,  and  in  some  persons  it  is  congenital.  The 
tongue  may  become  dry  from  persistent   openness   of  the  mouth, 


EXAMINATION    OF    PATIENT.  25 

as  during  sleep,  or  from  coma,  and  has  no  significance.  Among 
chronic  diseases  the  tongue  is  most  apt  to  be  found  dry  in 
diabetes. 

A  dry  tongue  is  never  a  favorable  sign.  It  is  present  in 
about  fifty  per  cent,  of  fatal  cases;  more  than  any  other  it  fore- 
tells death.     A  moist  or  humid  tongue  is  a  favorable  sign. 

The  dryness  first  invades  the  tip  and  extends  up  the  centre. 
A  dry  tongue  generally  indicates  nervous  depression,  often 
shown  by  low  muttering  delirium.  This  depression  is  often  due 
to  want  of  sleep.  Narcotics,  therefore,  like  chloral,  bromide  of 
potassium,  or  opium,  by  inducing  sleep,  soothe  and  strengthen 
the  nervous  system,  and  indirectly  moisten  the  tongue. 

The  dry  tongue  is  often  an  indication  for  alcoholic  stimu- 
lants. The  two  chief  uses  of  alcohol  are  to  assist  digestion 
and  to  sustain  the  nervous  system.  Now  sleep  is  the  best 
restorative;  hence  fever  patients  who  sleep  well  do  not  as  a  rule 
require  stimulants. 

But,  if  in  spite  of  sleep  the  tongue  remains  dry  and  delirium 
persists,  then  alcohol  is  indicated.  Usually  a  patient  with  a  dry 
tongue  has  a  frequent,  quick  and  compressible  pulse  calling  for 
alcoholic  stimulation. 

If  the  alcohol  makes  the  tongue  drier  and  more  coated,  it 
is  contraindicated.  In  the  aged,  the  tongue  often  becomes  dry 
without,  fever. 

The  color  of  the  tongue  is  a  useful  sign.  A  broad,  pale, 
flabby  teeth -indented  tongue  indicates  anaemia  with  a  relaxed 
condition  of  the  tissues.  This  tongue  is  met  with  in  chlorosis, 
and  in  some  chronic  diseases,  as  Bright's,  and  always  signifies 
the  need  of  iron. 

In  diabetes  the  tongue  becomes  smooth,  glazed,  shiny, 
beefy  looking,  abnormally  clean  and  often  very  dry.  If  the 
tongue  be  red,  too  clean,  too  smooth  or  slightly  furred,  it  points 
to  an  irritable  state  of  the  stomach,  to  dyspepsia.  It  is  met  with 
in  drunkards  and  in  phthisis  when  the  intestines  are  ulcerated, 
and  in  tubercular  peritonitis.  One  minim  of  Fowler V  solution 
given  before  meals  will  improve  this  tongue.  The  tongue  is 
exceedingly  red   in  scarlet  fever,  and  is   known  as  the   "straw- 


26  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

berry   tongue."     A   red,    smooth   tongue   is    a    sign    of   failing 
nutrition. 

The  "  nervous  tongue  "  is  very  slightly  coated  and  covered 
with  a  slight  froth,  and  is  met  with  in  persons  of  nervous  tem- 
perament, and  in  cases  where  the  nervous  system  has  been  de- 
pressed by  overwork,  and  worry. 

The  coating  of  the  tongue  is  hardly  discernible  in  health; 
but  in  disease  the  epithelium  accumulates,  and  the  tongue  has  a 
loaded,  whitish  appearance  due  to  an  excess  of  white  epithelium. 
The  coat  is  apt  to  be  yellowish  in  disturbances  of  the  liver,  and 
of  brown  or  very  dark  hue  when  the  blood  is  contaminated. 

There  are  many  healthy  persons  who  wake  up  every  morn- 
ing with  their  tongues  covered,  more  especially  at  the  back, 
with  a  heavy  coating,  which  wears  off  after  a  meal.  The  tongue 
may  be  bare  of  its  epithelium  in  certain  instances  of  scurvy, 
chronic  diarrhoea,  dysentery,  malaria,  scarlet  fever  and  typhoid 
fever. 

Local  causes  often  coat  the  tongue.  Enlarged  tonsils  often 
coat  the  back  of  the  tongue.  Decayed  teeth  often  fur  a  portion 
of  the  tongue.  Excessive  smoking  almost  always  coats  the 
tongue.  A  coated  tongue  very  frequently  indicates  derangement 
of  the  stomach,  bowels  or  liver. 

If  the  patient  be  constipated,  and  the  stools  light  colored^ 
and  the  tongue  coated,  give  calomel  with  extract  of  belladonna, 
or  hyoscyamus. 

If  the  bowels  are  freely  open,  and  the  tongue  still  coated, 
give  in  addition  to  the  above,  five  drops  each  of  tincture  of  mix 
vomica  and  dilute  nitric  acid  thrice  daily. 

After  an  acute  illness  like  typhoid  fever,  the  tongue  some- 
times parts  with  its  coating  in  flakes. 

The  manifestations  afforded  by  the  tongue  which  are  indi- 
cative of  danger,  are  tremulous  action,  dryness,  a  livid  color,  a 
very  red,  shining  or  raw  aspect,  and  a  heavy  coating  of  a  dark 
or  black  hue  (Ringer  and  DaCosta). 

Sensations  of  Patients. — Sick  persons  have  many  disagreeable 

feelings.     They  complain  of   chills,   heat,   languor,  restlessness 

and  of  uneasiness;  but  their  most  constant  complaint  is  of  pain. 

Pain  may  be   dull  or  gnawing,  acute   and  lancinating,  per- 


EXAMINATION    OF    PATIENT.  27 

nianent  or  remitting.  A  dull  pain  is  generally  persistent.  It  is 
present  in  congestions,  in  chronic  inflammations,  and  in  acute 
inflammations  of  the  parenchymatous  viscera,  and  of  mucous 
membranes. 

Acute  pain  is  usually  remittent  and  not  so  fixed  to  one  spot. 
It  is  present  in  spasmodic  affections,  in  neuralgia,  and,  with  ex- 
tremely sharp  and  lancinating  pangs,  in  malignant  disease. 

Pain  varies  much  in  intensity.  It  is  sometimes  so  extreme 
as  to  cause  death.  We  have  to  judge  of  its  severity  partly  on 
the  testimony  of  the  sufferer. 

The  seat  to  which  the  pain  is  referred  is  far  from  being 
always  the  seat  of  the  disease.  A  calculus  in  the  bladder  may 
produce  dragging  sensations  extending  down  the  thighs;  inflam- 
mation of  the  hip  joint  gives  rise  to  pain  in  the  knee;  disorders 
of  the  liver  occasion  pain  in  the  right  shoulder.  The  pain  is 
either  transmitted  in  the  course  of  a  nerve  involved,  or  is  sym- 
pathetic. 

Pain  in  diseases  of  the  periosteum  and  bones  is  mostly 
boring  and  constant;  in  the  serous  membranes,  sharp;  in  the 
mucous  membranes,  dull;  and  in  the  skin,  burning  or  itching. 

Pain  produced  by  pressure  is  called  tenderness  (DaCosta ). 

Temperature. — The  clinical  thermometer  may  be  put  under 
the  tongue,  or  in  the  axilla,  or  in  the  rectum.  The  rectal  tem- 
perature is  about  one  degree  higher  than  the  mouth  or  axillary 
temperature.  The  temperature  in  health  varies  in  the  24  hours. 
Durins;  the  dav,  between  9  a.  m.  and  4  p.  ]\r.,  the  healthv  tern- 
perature  is  usually  about  99'  F.,  or  it  may  rise  to  99.5°  F.  Any 
rise  above  99.5°  F.  constitutes  fever.  At  midnight  the  temper- 
ature is  about  97°  F.,  or  even  96"  F.  The  temperature  should 
be  taken  in  the  morning  about  7,  and  in  the  evening  at  the  same 
hour.  If  only  a  single  observation  be  taken,  it  is  best  done  in 
the  evening;. 

While  any  elevation  of  temperature  above  99.5°  F.  in- 
dicates disease,  it  need  hardly  be  pointed  out  that  a  normal 
temperature  does  not  necessarily  indicate  health.  Many  diseases, 
both  acute  and  chronic,  during  their  whole  courses  are  unat- 
tended with  fever.  As  a  rule,  the  morning  temperature  is  Lower 
than  the  evening.     In  rare  cases  the  reverse  happens.     In  some 


28  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

chronic  cases,  as  phthisis,  and  sub -acute  rheumatism,  the  fever 
may  last  only  a  few  hours  during  the  day. 

In  ordinary  cases,  the  pulse  and  temperature  rise  synchron- 
ously, and  every  degree  above  981  F.  corresponds  with  an 
increase  of  ten  beats  of  the  pulse.  When  the  temperature  ex- 
ceeds 106°  F.,  the  patient  may  be  looked  upon  as  in  danger, 
except  the  rise  be  due  to  malarial  fever.  Under  these  circum- 
stances, it  is  rapid,  occurring  in  a  person  who  yesterday,  or  but 
a  few  hours  before,  was  healthy.  In  typhoid  fever  a  tempera- 
ture of  105°  F.  is  proof  of  grave  disease.  In  pneumonia,  a 
temperature  above  104°  F.  is  a  symptom  of  very  serious 
seizure. 

Stability  of  temperature  from  morning  to  evening  is  a  good 
sign;  the  temperature  remaining  the  same  from  evening  till 
morning  is  a  sign  that  the  patient  is  getting  worse.  If,  after  the 
defervescence,  the  thermometer  again  indicates  a  decided  rise,  it 
shows  a  return  of  the  malady  or  complication. 

Specific  forms  of  febrile  diseases  have  their  characteristic 
temperature  records.  In  measles,  for  instance,  the  temperature 
rises  toward  the  breaking  out  of  the  rash,  reaches  its  height 
with  the  period  of  eruption,  and  in  twenty -four  hours  succeed- 
ing it  falls  rapidly.  In  scarlet  fever  the  thermometer  marks  105° 
F.  or  more  at  the  beginning,  and  the  fever  gradually  sub- 
sides. Typhoid  fever  has  its  characteristic  record;  so  have  the 
malarial  fevers  theirs.  The  temperature  of  tetanus  rises  to  great 
heights  before  death. 

A  temperature  above  107°  F.  is  almost  certain  to  be  the 
forerunner  of  a  fatal  issue.  But  recovery  may  take  place.  Da- 
Costa  reports  a  case  of  cerebral  rheumatism,  in  which  the  ther- 
mometer marked  110"  F.,  yet  the  patient  got  well. 

In  a  case  of  injury  to  the  spine  after  a  fall,  reported  by 
Teale,  the  young  lady  lived,  though  the  temperature  reached 
above  122°  F.,  and  ranged  for  days  between  112°  F.  and 
114°  F.  A  case  of  hysteria  and  intercostal  neuralgia  has 
been  reported,  in  which  the  thermometer  registered  117°  F., 
and  the  patient  recovered.  The  temperature  may,  also,  be  very 
high  for  a  short  time,  from  emotion.  In  children  the  tempera- 
ture is  relativelv  higher  than  in  adults  with  the  same  disturbance. 


EXAMINATION    OF    PATIENT.  29 

Tlie  thermometer  assists  us  in  diagnosis.  We  should  search 
carefully  to  discover  the  cause  of  the  fever.  The  fever  may  be 
due  only  to  the  acute  contagious  diseases,  acute  inflammation  of 
some  organ,  rheumatism,  gout,  or  to  the  diseases  causing  chronic 
fever.  In  the  acute  specific  diseases,  fever  and  sore  throat  would 
point  to  scarlet  fever;  severe  backache,  headache  and  sore  throat 
to  small-pox;  coryza,  with  cough,  to  measles.  Severe  fever, 
ushered  in  by  a  severe  rigor,  with  severe  headache,  and  pain  in 
the  limbs,  would  suggest  typhus;  wmilst  dull,  frontal  headache, 
with  diarrhoea,  would  strongly  point  to  typhoid  fever.  If  the 
second  day  passes  without  the  occurrence  of  a  rash,  the  case  in 
all  probability,  is  not  one  of  scarlet  fever;  for  the  rash  of  this 
disease  apj)ears  on  the  first  or  second  day.  If  the  third  day 
passes  without  a  rash,  the  case  is  not  small-pox,  for  this  rash 
usually  apj:)ears  punctually  on  the  third  day.  If  the  fourth  day 
passes  without  a  rash,  the  case  is  not  one  of  measles.  If  the 
fifth  day  passes  without  a  rash,  the  case  is  not  typhus,  for  the 
rash  punctually  appears  on  this  day. 

The  diagnostic  value  of  temperature  is  shown  in  the  follow- 
ing :  A  patient  is  suddenly  seized  with  severe  pain  on  the  side 
of  the  chest.  The  pain,  shooting  or  stabbing  in  character,  is  in- 
tensified on  coughing  or  deep  breathing.  This  is  the  character- 
istic pain  of  pleurisy  and  of  pleurodynia;  one  an  inflammatory 
disease,  the  other  a  non- inflammatory  disease — which  is  it  ( 
Before  the  physical  signs  develop  nothing  but  the  thermometer 
will  solve  the  difficulty.  If  the  attack  be  pleurisy,  an  inflamma- 
tory disease,  there  is  fever,  whereas  if  the  attack  be  pleurodynia, 
a  non-inflammatory  disease,  fever  is  absent. 

The  temperature  rises  rapidly  in  most  inflammations,  in 
typhus,  scarlet  fever,  measles,  erysipelas,  etc.  In  some  diseases 
the  temperature  rises  more  gradually.  This  happens  in  most 
cases  of  tuberculosis  and  in  almost  all  cases  of  typhoid  fev(  r, 
and  sometimes  in  rheumatism  and  pleurisy. 

The  duration  of  the  fever  often  aids  in  the  diagnosis.  In 
most  acute  diseases  the  fever  usually  passes  away  by  the  fifth  or 
tenth  day.  In  some  cases  of  typhoid  fever  the  symptoms  are  not 
sufficiently  marked  to  enable  the  doctor  to  decide  whether  the 
case  is  one  of  typhoid  fever,  tuberculosis  or  phthisis.     If  the 


30  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

fever  goes  on  beyond  thirty  days  then  probably  the  patient 
suffers  from  consumption,  and  each  additional  day  of  fever 
strengthens  this  conclusion. 

A  sudden  and  considerable  fall  of  temperature,  if  not  due 
to  the  natural  termination  of  the  illness,  means  sudden  collapse. 
It  is  oftenest  met  with  in  typhoid  fever,  and  it  means  hemorrhage 
into  the  bowels,  or  perforation  of  the  intestines.  Each  week  in 
typhoid  fever  a  great  morning  fall  often  occurs.  A  fall  equal  to 
that  due  to  hemorrhage  or  perforation,  may  occur  at  any  time, 
but  the  fall  with  these  accidents  is  more  persistent,  and  is  always 
accompanied  by  the  symptoms  of  collapse. 

Chronic  Fever. — In  some  diseases  fever  may  persist  for 
weeks  or  months,  and  by  its  very  duration  help  the  diagnosis. 
In  most  cases,  when  the  fever  has  lasted  only  a  short  time,  the 
other  symptoms  reveal  the  nature  of  the  disease;  but  frequently 
the  nature  of  the  malady  remains  for  a  long  time  obscure,  and 
then  the  fever  aids  in  the  diagnosis. 

Since  most  acute  illnesses  come  to  an  end.  in  the  great  major- 
ity of  cases,  before  the  thirtieth  day,  we  may  take  that  as  the 
limit  of  acute  fever. 

Chronic  fever  occurs  in  phthisis,  abscess,  syphilis,  ague, 
rheumatism,  in  most  cases  of  leucocythemia,  pernicious  anaemia, 
and  chronic  pyaemia.  The  temperature  is  an  index  of  the  activ- 
ity of  the  disease.  If  the  fever  be  high  the  disease  is  active. 
In  some  very  chronic  cases  of  phthisis  the  disease  advances  too 
slowly  to  elevate  the  temperature. 

By  the  aid  of  the  thermometer  we  can  often  diagnose 
phthisis,  before  we  can- detect  any  physical  signs,  and  at  a  period 
when  symptoms  themselves  are  insufficient  to  justify  a  grave 
diagnosis.  A  patient  suffers  from  chronic  fever.  AVhat  is  the 
cause  of  it  i  So  far  as  we  at  present  know  chronic  fever  occurs 
only  in  tuberculosis,  catarrhal  pneumonia,  large  abscesses,  rheu- 
matism, ague,  occasionally  in  syphilis,  in  some  cases  of  leucocy- 
thaemia,  in  lymphadenoma,  and  in  pernicious  anaemia  and  chronic 
pyaemia.     The  discrimination  of  these  diseases  is  rarely  difficult. 

The  following  cases  illustrate  the  usefulness  of  the  ther- 
mometer in  doubtful  cases  of  phthisis: 


EXAMINATION    OF    PATIENT.  31 

A  patient  is  taken  rather  suddenly  ill.  His  face  is  flushed, 
eyes  bright,  pulse  quick.  The  temperature  is  very  high.  There 
is  no  headache,  no  delirium,  no  diarrhoea.  So  weak  is  he  that 
he  stays  in  bed.  He  continues  in  this  state  for  a  month  or  five 
weeks  when  distinct  physical  signs  at  the  apices  of  the  lungs  ap- 
pear, accompanied  by  cough  and  expectoration,  and  possibly 
slight  haemoptysis. 

A  woman  between  30  and  35  years  of  age,  fails  slightly  in 
health,  complains  of  slight  weakness,  is  soon  tired,  but  is  never 
ill  enough  to  be  confined  to  bed.  Her  appetite  is  bad.  There 
is  a  trifling  cough  with  expectoration  slightly  streaked  with 
blood  once  or  twice.  There  may  be  a  family  predisposition  to 
phthisis.  No  physical  signs  are  aiDparent;  yet  the  temperature, 
rising  nightly  to  101  or  102°  F.,  declares  the  true  nature  of 
the  disease,  (Ringer  and  Da  Costa). 


CHAPTER  II. 
DISEASES  IN  GENERAL. 


ABORTION. 

T.  Gaillarcl  Thomas  says,  that  the  uterus  is  the  organ 
which  divides  one  sex  from  the  other,  that  this  organ  has  three 
entirely  distinct  and  different  periods  of  existence,  that  front 
birth  to  the  age  of  thirteen,  or  puberty,  it  is  undeveloped  and 
unimportant,  and  that  from  thirteen  to  fifty  its  career  is  one  of 
intense  activity,  and  has  a  marked  influence  upon  the  whole  being 
of  a  woman,  that  from  the  age  of  about  fifty,  to  the  close  of  life 
it  sinks  into  insignificance  again,  and  becomes  an  atrophied  and 
unimportant  organ — of  no  use  whatever,  that  impregnation  and 
conception  are  two  entirely  different  things,  that  the  ova  may 
become  impregnated  twelve  times  a  year,  and  yet  conception  may 
not  result;  that  conception  is  the  fixation  of  the  impregnated  ovum; 
that  up  to  two  and  a  half  months  there  is  no  placenta,  so  far  as 
abortion  is  concerned,  that  from  the  third  month  the  placenta  is 
the  all-important  element  as  regards  abortion;  that  abortion  is  to 
be  defined  as  the  premature  casting  off  of  the  product  of  concep- 
tion before  the  end  of  the  fourth  month;  that  between  the  end  of 
the  fourth  month  and  the  end  of  the  sixth  month  it  is  called  mis- 
carriage, and  that  between  the  end  of  the  sixth  month  and  the 
end  of  the  ninth  month  it  is  called  premature  labor., 

When  abortion  occurs,  one  of  four  things  may  take  place: 
First,  the  entire  contents  of  the  uterus — the  decidua  vera,  the 
decidna  reflexa,  the  amnion,  the  chorion,  and  the  foetus  may  he 
expelled.      Second,  the  foetus  may  be  expelled  with  the  amnion 


ABORTION.  33 

and  chorion,  while  the  decidua  vera  and  reflexa  are  left  in  the 
uterus.  These  membranes  will  come  away  later  in  the  lochial 
discharge.  Third,  the  foetus  alone  may  be  expelled.  This  is  a 
complicated  case.  In  this  case  the  uterus  must  be  emptied  of 
its  contents  or  the  patient  will  have  a  violent  chill  and  high 
fever,  with  all  the  signs  of  septicaemia.  Fourth,  the  foetus  and 
membranes  may  be  expelled,  and  the  placenta,  when  one  is 
formed,  left  behind.  Thus,  we  see  that  abortion  does  not  always 
occur  in  the  same  way,  and  that  the  physician  must  treat  each 
case  according  to  its  character. 

Causes. — 1.  Carbonic- oxide  gas  inhaled  by  the  mother  is 
more  certain  to  produce  uterine  contractions  than  ergot.  The 
crowding  together  within  confined  quarters  of  pregnant  women 
will  cause  a  large  number  to  abort,  due  to  the  poisoning  of  their 
blood  by  this  gas.  This  gas,  generated  after  death,  produces 
uterine  contraction,  and  post-mortem  delivery  of  pregnant 
women.  2.  The  poisons  in  the  blood  produced  by  small-pox, 
scarlatina,  measles  and  malaria.  3.  Chorea,  tetanus,  and  reflex 
influences,  such  as  fright.  4.  Certain  drugs,  such  as  ergot, 
cotton-root,  etc.  5.  Anything  which  will  kill  the  foetus  will 
produce  an  abortion,  such  as  a  twist,  or  knot  in  the  umbilical 
cord,  syphilis,  a  kick  or  blow  irpon  the  abdomen.  6.  Retroflex- 
ion of  the  uterus.  In  anteflexion  of  the  uterus,  sterility  is  com- 
mon, but  endometritis  and  abortion  are  rare.  7.  Uterine  fibroids 
and  other  neoplasms,  and  laceration  of  the  external  os.  8.  Some- 
times jars  to  the  body  from  vomiting,  coughing  and  straining, 
from  railroad  journeys,  from  violent  exercise,  from  falls,  and  the 
like.  A  large  proportion  of  abortions  occur  about  the  end  of 
the  third  month.  During  an  abortion,  the  attitude  of  the  physi- 
cian, beyond  the  control  of  hemorrhage,  should  be  an  expectant 
one.  In  habitual  abortion  the  most  common  causes  are  syphilis 
and  retroflexion  of  the  uterus.  There  are  many  women  of  nerv- 
ous temperament  in  whom  the  slightest  cause  is  often  sufficient 
to  induce  an  abortion;  while,  in  others,  it  is  exceedingly  difficult 
for  them  to  get  rid  of  the  contents  of  the  uterus  before  the  nor- 
mal end  of  pregnancy. 

This  is  shown  in  attempts  at  criminal  abortion.     Lusk  re- 
lates the  case  of  a  peasant  who  took  his  wife,  while  pregnant, 


34  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

behind  Mm  on  horseback  and  started  off  with  her  at  full  gallop, 
with  the  view  of  causing  her  to  miscarry.  Having  thus  thor- 
oughly shaken  her,  he  dropped  her  suddenly  to  the  ground  with- 
out slackening  his  speed.  This  brutal  manoeuvre  he  repeated 
twice,  without  the  least  success.  Thomas  mentions  cases  of 
pregnant  young  women  in  Paris  who  attenrpted  suicide  by  jump- 
ing into  the  Seine,  and  were  rescued  and  went  on  to  full  term. 
Pregnant  women,  excited  by  an  alarm  of  fire,  have  jumped  from 
an  upper  window,  breaking  several  bones,  and  have  j)assed  on  to 
full  term  as  though  nothing  had  happened. 

Prognosis. — The  prognosis  is  good,  except  in  criminal  cases. 

Dangers. — 1.  Hemorrhage.  2.  Putrid  intoxication  from  ab- 
solution of  the  decomposing  product  of  conception.  3.  Septi- 
caemia and  peritonitis.  In  this  case  the  septic  material  is  conveyed 
to  the  womb  by  the  hand  or  instruments  of  the  physician.  4. 
Suppurative  arthritis.  5.  Cellulitis  and  abscess.  6.  Embolism. 
This  may  cause  hemiplegia.  7.  Air  in  the  veins.  The  air  is 
usually  introduced  through  a  hollow  instrument  used  in  the 
uterus.     8.  Tetanus.     This  comes  from  putrid  infection. 

Symptoms. — There  are  three  essential  symptoms:  1.  Hem- 
orrhage.    2.  Pain.     3.   Vomiting;  this  last  may  be  absent. 

Treatment. — The  treatment  is  divided  into:  1.  Prophylaxis 
in  cases  of  habitual  abortion.  If  the  cause  be  syphilis,  give  the 
antisyphilitics.  If  the  cause  be  displacements  of  the  uterus, 
correct  these.  If  the  cause  be  nerve  irritability,  give  the  patient 
teaspoonful  doses  of  the  fluid  extract  of  viburnum  prunifolium 
three  times  daily,  beginning  two  days  before  the  menstrual  date, 
and  continuing  for  eight  days,  with  the  patient  in  bed.  2.  Ar- 
rest of  threatened  abortion.  Keep  the  patient  quiet  in  bed  and 
give  the  following: 

jfc     Potassii  Bromidi gr.  x. 

Chloral  hydratis gr.  vi. 

Morphinse  sulphatis gr.  \. — M. 

Sig. :     One  dose. 

Kepeat  if  necessary.  The  chloral  induces  sleep,  the  bromide 
has  a  sedative  effect  upon  the  nervous  system,  and  the  morphine 
robs  life  of  its  cares.  If  the  patient  be  bleeding  freely,  apply  a 
tampon,  and  remove  it  in  twenty-four  hours.     In  the  first  two 


ABORTION.  35 

months  little  treatment  besides  rest  in  bed  for  a  few  days  is  re- 
quired. 3.  The  treatment  of  inevitable  abortion.  Get  the 
woman  through  with  the  abortion  as  quickly  as  possible,  and 
leave  nothing  in  the  uterus  for  bacteria  to  work  on.  Your 
hands,  instruments,  sponges,  and  tampon,  if  used,  should  all  be 
aseptic. 

If  the  abortion  is  going  on  and  the  woman  is  losing  large 
quantities  of  blood,  the  tampon  is  the  best  remedy.  When  in 
the  third  month  the  ovum  is  thrown  off  without  rupture  of  the 
foetal  membranes,  the  hemorrhage  is  rarely  dangerous.  The 
treatment  is  very  simple — a  carbolized  douche  morning  and 
evening.  When  the  sac  ruptures  the  hemorrhage  is  usually  pro- 
fuse. The  treatment  indicated  in  this  case  is  to  check  the  hem- 
orrhage by  a  tampon,  and  afterwards  empty  the  uterus  by  means 
of  the  finger  or  curette.  Do  not  give  opium  to  quiet  pain.  Do 
not  give  ergot  unless  the  cervix  is  well  dilated.  A  good  tampon 
is  made  by  soaking  cotton  wool  in  carbolized  water,  five  per 
cent,  solution,  and  after  pressing  out  the  excess  of  fluid,  make 
into  flat  pieces,  and  pack  well  around  the  vaginal  portion  then 
over  the  os.  A  tampon  should  not  remain  over  twelve  hours  in 
the  vagina.  In  emergency  a  soft  towel,  handkerchief,  strips  of 
cotton  cloth  and  a  roller  bandage  may  be  used  for  a  tampon. 
4.  The  treatment  of  neglected  abortion  is  to  clean  out  the 
uterus  with  the  finger  or  dull  wire  curette  and  use  carbolized 
douche  (3i-Oj).  The  temperature,  if  high  will  soon  fall  after 
the  curettage  and  douche. 

Chances  of  error  in  connection  with  abortion. — 1.  Could 
a  woman  have  an  abortion,  say,  at  the  end  of  the  third  month, 
and  at  the  end  of  six  months  from  that  time  be  delivered  of  a 
fully- developed  living  child?  Yes,  and  the  explanation  is,  that 
one  of  a  pair  of  twins  has  been  cast  off  and  the  other  has  gone  to 
full  term.  2.  A  woman  has  an  abortion  and  the  foetus  is  cast  off 
with  all  its  membranes  entire.  In  a  month  from  the  date  of  the 
abortion  the  woman  suddenly  dies  in  collapse.  An  examination 
shows  that  in  addition  to  the  foetus  in  the  uterus  there  lias  been 
an  extra-uterine  one,  and  the  fatal  result  was  due  to  rupture  of 
the  Fallopian  tube.  3.  A  woman  has  an  abortion  and  the  foetus 
is   cast  off  but  not  all  the   membranes.     The  next  month  the 


36  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

patient  does  not  menstruate.  About  the  end  of  the  ninth  month, 
the  uterus  begins  to  contract,  but  instead  of  a  living  child  being 
delivered,  a  bucketful  of  hydatids  is  cast  off.  These  little  cysts 
developed  in  the  retained  membranes.  4.  The  foetus  is  cast  off 
with  the  lower  portions  of  the  foetal  shell,  leaving  the  remainder 
of  the  shell  still  in  the  uterus.  This  may  remain  for  months  or 
years  constituting  "molar  pregnancy." 

Artificial  Production  of  Abortion. — Never  induce  an  abortion 
without  first  having  a  consultation. 

Indications. — Whenever  it  is  felt  that  the  prolongation  of 
pregnancy  is  going  to  destroy  the  life  or  intellect,  or  to  perman- 
ently ruin  the  health  of  a  patient,  abortion  should  be  brought  on. 

The  methods  by  which  Abortion  is  brought  on.  1.  The  first 
method  is  to  introduce  a  metallic  sound  into  the  os-uteri,  and 
push  it  forcibly  through  the  foetal  shell.  If  there  be  a  brutal 
and  stupid  method  of  producing  abortion,  it  is  certainly  this.  It 
is  the  one  commonly  practiced  in  criminal  abortions.  It  will 
kill  the  foetus,  but  it  may  not  come  away  and  thereby  produce 
putrefaction  and  septicaemia.  This  method  should  not  be  used. 
2.  The  second  method  is  to  take  sponge  tents,  and  introduce 
them  into  the  os  internum.  This  method  should  be  avoided.  3. 
Certain  drugs,  such  as  ergot,  savin,  pennyroyal,  viscum  album, 
and  the  root  of  the  cotton  plant.  Xo  scientific  physician  would 
ever  think  of  placing  any  dependence  upon  them  whatever.  4. 
The  best  method  and  the  one  which  is  sure  and  safe  is  as  fol- 
lows: Anaesthetize  the  patient  with  ether,  and  place  her  in  the 
Sims  position.  Fill  the  vagina  with  bichloride  solution,  (1  to 
2,000).  Xext  you  catch  the  cervix  with  a  little  tenaculum  and 
dip  it  below  the  surface  of  the  bichloride  solution.  "With  a 
divulsor  you  stretch  the  cervical  canal  until  you  can  introduce 
your  finger.  You  next  introduce  a  glass  plug  as  large  as  the 
finger  into  the  cervix.  You  then  pack  the  vagina  with  iodoform 
gauze  and  then  apjuy  a  tampon.  This  is  all  yoiuhave  to  do. 
The  plug  and  the  tampon  may  be  left  in  position  for  thirty -six 
to  forty- eight  hours. 

You  may  have  to  stretch  the  os  again  and  put  in  a  larger 
plug.  The  plug  should  be  an  inch  and  a  half  in  length  with  a 
shoulder  which  prevents  its  entrance  into  the  uterine  cavity. 


ABORTION ABSCESS. 

PRESCRIPTIONS  FOR  ABORTION. 


37 


IJ     Tincturse  opii, ZITxx-xxx. 

Sig. :     Mix  with  three  tablespoonfuls   of  boiled  starch   and  in- 
ject into  the  rectum.  — Parvin. 

5     Misturas  asafcetidse Sviij. 

Sig.:     A    tablespoonful    several    times    daily.        (In    habitual 
abortion.)  — Negri. 


1J     Tincturse  ferri  chloridi Sss. 

Potassii  chloratis 3j  • 

Sy rupi  simplicis Sj • 

Aquse  menthse  piperita?  ad Siv. — M. 

Sig. :     A  dessertspoonful  in  a  wineglassful  of  water  after  meals. 
(When  due  to  fatty  degeneration  of  the  placenta.)  — Strother. 

IJ      Auri  et  sodii  chloridi gr.  iv. 

Aquse  destillatae Sj- — M. 

Sig.:      Six     drops     in    a  tablespoonful  of    water  three    times 

daily   after   meals.     (In   habitual   abortion.)  — Martin. 


ABSCESS. 

A  circumscribed  collection  of  pus  in  any  tissue  is  called  an 
abscess.  Pus  in  a  preformed  cavity  is  called  empyema.  An 
abscess  is  always  the  result  of  an  inflammatory  process. 

Varieties. — When  an  abscess  forms  rapidly  it  is  called 
acute,  hot,  or  phlegmenous,  and  its  pus  is  living.  When  it  is  of 
slow  formation,  it  is  called  chronic,  cold,  lymphatic  or  tubercu- 
lous, and  its  pus  is  dead. 

Symptoms. — We  may  have,  1.  History  of  an  injury.  2. 
Defective  nutrition.  3.  Kigor  or  chills.  4.  Elevation  of  tem- 
perature. 5.  Fluctuation.  6.  The  five  cardinal  symptoms  of 
inflammation  which  are,  redness,  swelling,  heat,  pain  and  loss  of 
function.  If  the  abscess  be  acute  or  hot,  the  pus  is  thick  and 
creamy,  the  walls  of  the  cavity  are  tense,  the  surrounding  tissues 
are  indurated,  and  there  is  a  tendency  to  burst  at  the  point  of 


38  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

least  resistance.  If  the  abscess  be  chronic  or  cold,  the  pns  is 
thin,  serons  and  gelatinous,  the  walls  are  flabby,  the  surrounding 
tissues  are  not  indurated. 

Causes. — The  tendency  of  late  is  to  regard  all  acute 
abscesses  as  due  to  a  special  micro-organism,  the  staphylococcus 
pyogenes  aureus.  Chronic  abscess  is  due  to  the  bacillus  tuber- 
culosis. 

All  varieties  may  start  from  injury. 

The  origin  of  pus  in  an  abscess  is  emigration  of  white  cor- 
puscles, proliferation  of  connective  tissue  cells,  granules  of  fat, 
and  debris  of  inflamed  tissue  floating  in  serum. 

Varieties  of  Pus. — Pus  when  thick  and  creamy  is  known  as 
"  healthy  "  or  laudable  pus,  or  living  pus;  when  thin  and  watery 
"  puriform  fluid  "  or  dead  pus;  when  blood-stained  "sanious;" 
gummy  pus  in  syphilis;  and  contagious  pus  in  small-pox,  gonor- 
rhoea and  venereal  ulcers. 

Diagnosis. — Abscess  must  be  diagnosed  from:  1.  Hemat- 
ocele. 2.  Cyst.  3.  Lipoma.  4.  Aneurism,  and  5.  Malignant 
tumors.  Hsematocele  has  a  rapid  growth,  evidence  of  an  injury, 
and  no  change  in  the  skin.  The  walls  of  a  cyst  are  distended 
by  fluid  which  distinctly  outlines  it.  In  fatty  tumor  or  lipoma, 
the  skin  is  unchanged  and  may  be  lifted  up  from  tumor.  In  an- 
eurism there  is  a  distinct  expansile  pulsation  synchronous  with 
the  heart's  action.  Pressure  on  the  artery  above  the  aneurism 
diminishes  its  size,  while  pressure  below  increases  its  size.  An 
aneurism  has  a  rasping  sound  like  sawing  wood.  The  pain  of 
aneurism  is  very  characteristic — sharp  and  lancinating  produced 
by  pressure  on  nerve. 

Use  a  hypodermic  syringe  to  make  the  diagnosis.  The  pain 
in  acute  abscess  is  at  first  dull  and  heavy  and  then  throbbing. 
There  is  not  much  pain  in  a  cold  abscess. 

We  speak  of  an  abscess  according  to  its  situation,  as  mam- 
mary, lumbar,  cerebral,  perineal,  post-pharyngeal,  etc. 

Prognosis. — Depends,  1.  On  the  size  of  the  abscess.  2.  On 
its  character.  3.  On  the  age  of  the  patient.  4.  Situation  of 
the  abscess.     5.  Condition  of  the  patient,  and  6.  On  its  cause. 

Treatment. — Never  squeeze  an  abscess  but  drain  it  freely. 
An  acute  abscess  should  be  opened  in  the  most  dependent  part, 


ABSCESS.  39 

using  a  sharp  bistoury  for  the  purpose;  press  out  gently  the 
accumulated  material,  wash  it  with  bichloride  of  mercury  (1  to 
1,000),  insert  a  drainage  tube,  and  place  upon  the  outside  iodo- 
form gauze.  We  do  not  open  a  chronic  abscess  but  aspirate  it. 
Do  not  allow  air  to  go  in.  A  small  amount  of  pus  may  be  ab- 
sorbed. 

Constitutional  Treatment.  Give  tonics,  such  as  iron,  qui- 
nine and  strychnine  together  with  good  nutritious  diet  and 
plenty  of  fresh  air. 

PRESCRIPTIONS  FOR  ABSCESS. 

|fc     Iodoforrai oiij. 

Aetheris 5  vi. — M. 

Sig. :     Inject  three  to  five   ounces    after  aspirating  the  abscess. 
(In  cold  or  tubercular  abscess.)  — Mosetig  Moorhof. 

JJr     Iodoformi    5ij- 

Glycerinae Siiss. — M. 

Sig.:    Inject  the  abscess  cavity,  after  evacuating  the  pus.     (In 
cold  or  tubercular  abscess).  — Billroth. 

JJr     Calcii  sulphidi gr.  ij. 

Sacchari  lactis gr.  xx. — M. 

In  chartulas  xx.  div.    Sig. :    Take  one  powder  every  hour  or  two. 

— Ringer. 

|fc     Emplastrum  belladonnas 

Sig. :  Apply  to  abscess  to  relieve  pain.  — Bartholow. 

Jfc     Potassii  permanganatis 5j- 

Aquse  destillatse Oj. — M. 

Sig. :    Apply  to  correct  the  fetor  of  abscess.  — Bartholow. 

JJr     Tincturse  iodi  sij- 

Sig.:    Apply  as  counter-irritant,  and  after  pus  is  evacuated  apply 

to  the  sac.  — Bartholow. 

Use  ether  sju-ay  to  produce  local  amesthesia,  for  opening 

abscesses. 


40  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ACIDITY. 

Acidity  is  not  a  disease,  but  a  symptom.  As  a  symptom 
it  has  no  special  diagnostic  value,  for  it  is  met  with  both  in 
functional  and  in  organic  disease  of  the  stomach. 

Excessive  acidity  occurs  from  various  causes.  The  gastric 
juice  may  be  secreted  in  large  quantities,  or  it  may  contain  an 
abnormal  amount  of  acid. 

But  excessive  acidity  is  far'  more  frequently  due  to  the  de- 
composition of  food,  and  to  a  process  of  fermentation  dependent 
rather  upon  scarcity  than  over- abundance  of  this  juice.  In  this 
case  it  manifests  itself  only  after  meals.  At  the  same  time  car- 
bonic acid  gas  may  be  generated,  causing  great  distension  and 
eructations,  or  belching  of  sour  liquid. 

Treatment. — Acids,  given  on  an  empty  stomach,  check  the 
secretion  of  the  acid  gastric  juice;  given  on  a  full  stomach,  they 
render  its  contents  more  acid;  hence,  if  there  is  an  excess  of  acid 
secreted  by  the  stomach,  they  should  be  given  before  meals,  in 
small  doses  and  well  diluted;  while,  if  there  is  too  little  acid 
secreted,  they  may  be  given  after  meals,  to  supply  the  deficiency. 

PRESCRIPTIONS  FOR  ACIDITY. 

JJr     Acidi  hydrochlorici  diluti Sj- 

Sig. :    Ten  drops  in  water  twenty  minutes  before  meals. 

Jfc     Tincturse  nucis  vomica? Sj. 

Sig. :  Five  drops  in  water  fifteen   minute  before  meals. — Ringer. 

{£•     Sodii  bicaibonatis oiij- 

In  pulveres  no  xii.  div. 
Sig. :  A  powder  in  a  wineglassful  of  water  after  meals. 

— Alonzo  Clark. 

Jfc     Sodii  bicarbonatis 5j. 

Pulveris  rhei Sss. 

Spirit!  menthse  piperita? 5ij- 

Aqua? — q.  s. — ad ' 5iv. — M. 

Sig. :  A  tablespoonful  after  meals.     (For  acidity,  combined  with 
constipation).  — Bellevue  Hospital. 


ACIDITY ACNE.  41 

Jfc     Pulveris  ipecac gr.  ss. 

Pulveris  rhei gr.  ij. 

Sodii  bicarbonatis gr.  xij . 

In  pulveres  no  xii.  dividenda. 
Sig. :     One  powder  every  four  to  six  hours  to  an  infant  one  year 
old.  — J-  Lewis  Smith. 

Alkalies  after  meals  are  only  palliative. 

Jfc     Glycerini    Siv. 

Acidi  tannici oij  •  — M. 

Sig. :    A  teaspoonful  before,  with,  or  after  meals.        — Bartholow. 

ACNE. 

Acne,  called  also^  Acne  Vulgaris,  or  Varus,  is  an  inflam- 
mation of  the  sebaceous  follicles  and  glands,  the  result  of 
accumulation  and  retention  in  them  of  sebaceous  matter.  If  the 
sebaceous  matter  be  retained  without  inflammation,  the  surface 
becomes  studded  with  black  specks,  and  the  affection  is  known 
under  the  name  of  comedones,  or  black-heads.  But,  sooner  or 
later,  the  sebum  plugs  give  rise  to  irritation,  act  as  thorns  in  the 
flesh,  and  excite  inflammation  and  suppuration  in  the  surround- 
ing tissues,  and  the  patient  is  said  to  have  acne. 

Acne  is  likely  to  occur  in  those  whose  skins  are  sensitive,  or 
whose  general  health  is  disordered.  It  is  a  frequent  affection 
and  is  resented  by  the  upper  classes  of  society  on  account  of  its 
disfigurement.  It  is  rarely  met  with  before  puberty — usually  be- 
gins between  the  ages  of  15  and  25.  Some  thought  that  there 
was  a  connection  between  acne  and  the  organs  of  generation,  as 
a  marriage  would  sometimes  moderate  its  violence,  and  Rigler 
very  rarely  saw  acne  in  eunuchs;  but  Hebra  said,  "I  cannot 
agree  with  Plenck's  dictum,  '  Matrimonium  varos  curat,'  but 
would  rather  say,  'Tempus  varos  curat.'  " 

Symptoms. — Acne  affects  most  frequently  the  face,  neck. 
shoulders,  back  and  chest.  The  starting  points  of  the  eruption 
is  the  accumulation  of  hardened  plugs  of  sebum  in  the  sebaceous 
follicles  (comedones)  which  are  black  upon  the  surface,  owing 
to  admixture  with  particles  of  dust.  Sometimes  a  small  nodule 
surrounds  each  follicle,  and  we  have  acne  punctata;  sometimes 
the  nodule  becomes  pustular,  and  we  have  acne  pustulosa;  some- 


42  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

times  there  is  a  decided  induration,  or  tubercle,  acne  indurata. 
In  severe  cases  some  of  the  sebaceous  glands  are  apt  to  be  the 
seat  of  distinct  abscesses.  If  these  inflammatory  centres  are 
allowed  to  run  their  course  unchecked,  they  leave  cicatrices 
which  resemble  the  pits  of  small-pox,  and  as  the  eruption  tends 
to  occur  in  successive  croj3s,  in  time  the  disfigurement  may  be 
considerable,  hence  the  disease,  though  trivial,  should  be  treated. 
A  burning  heat  is  occasionally  complained  of,  and  itching  is 
common. 

Diagnosis. — Tar  acne  may  be  mistaken  for  acne,  but  the 
history  of  the  patient  having  been  exposed  to  the  influence  of 
tarry  preparations,  or  their  external  use,  would  make  the  diag- 
nosis. In  tar  acne  there  is  a  black  speck  in  the  center  of  each 
nodule,  as  in  acne.  The  eruptions  which  frequently  occur  in 
those  who  are  taking  the  bromides  or  iodides  sometimes  resemble 
that  of  acne,  but  in  them  there  is  a  history  of  the  taking  of  one 
of  these  drugs,  and  there  is  an  absence  of  black  specks  in  the 
centre  of  the  nodules.  Syphilitic  eruptions  may  sometimes  be 
mistaken  for  acne;  but  in  the  former  the  eruption  commences 
after  the  poison  enters  the  system,  usually  affects  all  parts,  is 
more  or  less  coppery  in  chronic  stage,  is  often  in  circles  or  seg- 
ments of  circles,  ulceration  is  common,  itching  absent  always 
in  early  syphilis,  eruption  easily  removed  by  anti-syphitic  treat- 
ment; in  the  latter,  the  eruption  commences  between  puberty 
and  25,  is  limited  to  face,  chest  and  back,  is  bright  red,  is  never 
in  circles  or  segments  of  circles,  no  tendency  to  ulceration,  itch- 
ing often  present,  eruption  hard  to  remove  by  any  kind  of  treat- 
ment. 

Treatment. — Is  both  constitutional  and  local.  If  the  patient 
is  strumous,  phosphorous  and  cod-liver  oil  in  full  doses  should 
be  given.  If  the  eruption  aj3pears  in  an  aggravated  form,  arsenic 
should  be  given.  If  suppuration  is  a  prominent  feature,  the 
sulphide  of  calcium  may  be  tried. 

The  local  treatment  is  the  most  important:  1.  Press  out 
the  sebum  plugs  (comedones).  2.  Bathe  the  affected  parts  every 
night  and  morning,  with  water  as  hot  as  can  be  borne,  for  ten 
minutes,  and  afterwards   apply  friction  with  rough  towel.     3. 


ACNE.  43 

Acne  indurata  has  been  cured  by  applications  of  galvanism,  both 
local  and  central. 

PRESCRIPTIONS  FOR  ACNE. 

JJr     Syrupi  hypophos  comp Sviij. 

Sig. :     A  teaspoonful  after  each  meal.     (Acne  indurata). 

— Bartholow. 

J&     Liquor  potassii  arsenitis 5  vj . 

Sig. :     Three  drops  in  water  after  each  meal. 

J&     Liquor  potassse 3j. 

Aquse  Rosas 5iv. — M. 

Sig.:     Apply  with  a  soft  sponge  twice  daily.     Use  mutton  suet 
10  face  afterwards.  — Bartholow. 

Jir     Calcii   sulphidi..... gr.  xv. 

Sacchari  lactis oiij • 

In  chartulas  no  Lx.    div — M. 

Sig.:     Take  one  powder  three  times  a  day.  — Anderson. 

J&     Sulphuris  iodidi 5ss. 

Adipis sj.— M. 

Sig.:     Use  freely  over  the  eruption  night  and  morning.     (In  acne 
indurate  and  rosacea.)  — Ringer. 

JJr     Sulphuris 5j- 

Gly cerini  (Price) 5j  • 

Cold  cream Sj . — M. 

Sig. :     To  be  applied  firmly  every  night  short  of  causing  pain  or 
inflammation.  — Anderson. 

Jfc     Potassii  sulphureti 

Zinci  sulphatis aa 5j- 

Aqua?  rosse Sj. — M. 

Sig.:     Apply  to  the  face  on  muslin  twice  a  day  and  wash  the  face 
with  tar  soap.  — Anderson. 

Jfc     Lactis  sulphuris 

Glycerini 

Spirits  vini  rectificati 

Potassii  carbonatis 

Aetheris  sulphurici aa Sss. — M. 

Sig.:     Apply  to  face  at  bed-time.  — Teissl. 


44  A    COMPENDIUM    OF    PEACTICAL     MEDICIXE 

J£     Sulpburis  precipitatse 5ij- 

Camphor gr.  x. 

Gum  mimosa gr.  xx. 

Aquas  calcis 

Aquas  rosas. aa 5 iij . — M . 

Sig. :     Shake  the  bottle.     Apply  at  bed-time  and  in  the  morning 
remove  the  sulphur  without  wetting  the  skin.  — Kummerfeld. 

|£     Hydrargyri  chloridi  corrosivi gr.  xx. 

Glycerini    Sss. 

Spiriti  vini  rectificati Svij. 

Spiriti  rosmarini 5iv. — M. 

Sig.:     Apply  to  face.  — Bartholow. 

J&     Hydrargyri  iodidi  viridis gr.  x. 

Adipis Sj  • — M. 

Sig. :     Apply  to  face.  — Bartholow. 

{£     Hydrargyri  iodidi  rubri gr.  v. 

Adipis  Sj. — M. 

Sig.:     Apply  to  face.  — Bartholow. 

{Jr     Glycerini Sj  • 

Sig. :     Half  teaspoonful  after  meals.  — Bartholow. 

|fc     Sulphuris '•  •  •  oj  • 

Glycerini oj  • 

Aquae  rosse ,, oviij. — M. 

Sig.:     Apply    to  face  night  and  morning.  — Ringer. 

J$r     Hydrargyri  perchloridi Sj- 

Aquas  destillatas §iv. 

Ovorum  xxiv  albumen 

Succi  citri oiij. 

Sacchari o  viij. — M. 

Sig. :     Apply  to  the  face.  — Hebra. 

The  above  is  a  cosmetic  lotion  much   used  by  the  Orientals 
as  a  beautifier  of  the  skin,  and  is  often  of  use  in  acne. 

{{r     Potassii  acetatis oiv. 

Tincturse  nucis  vomica? 5ij- 

Extracti  rumicis  fluidi,  ad §iv. — M. 

Sig.:     One  teaspoonful,  well  diluted  after  meals.  — Bulkley. 


ACNE ACNE    ROSACEA.  45 

{&•     Potassii  acetatis Sj. 

Acidi  acetici 5ss. 

Spiriti  setheris  nitrosi Siss. 

Extracti  taraxaci  fluidi Sij. — M. 

Sig. :     A  teaspoonful  before  meals  in  water.  — Bulkley. 

jfc     Sulphuris  prsecipitatae 5 v. 

Glycerini 5iss. 

Spiriti  camphorse Sj- 

Aquse Siv. — M. 

Sig. :  Apply  with  a  brush  to  the  affected  part  before  retiring 
at  night.  — Lailler. 

{fc     Sulphuris  prsecipitatse 3j- 

Glycerinse 3j  • 

Spiriti  vini  rectificati Sss. 

Aquse  rosas ad Siv. — M. 

Ft.  lotis. 

Sig.:  To  be  painted  on  at  night  after  steaming  the  face  and 
washing  it  with  sand  soap.  To  be  washed  off  in  the  morning 
with  warm  gruel,  and   the  face  powdered   with    the  following  : 

|fc     Zinci  oleatis 

Pulveris  talc aa Sj- — M. 

Sig.:     To     be   dusted   on   every   morning.  — Jamieson. 

ACNE  ROSACEA. 

Called  also  Rosacea,  or  Copper-nose,  is  a  very  common  affec- 
tion, but  not  so  common  as  ordinary  acne. 

Causes. — Intemperance  is  the  most  frequent  cause  in  males. 
Debility  is  the  usual  cause  in  females.  Those  whose  faces  are 
exposed  to  great  cold  or  heat,  as  cab -drivers,  bakers  and  cooks, 
are  liable  to  have  copper-nose.  In  males  the  disease  usually  ap- 
pears about  middle-life;  in  females  about  puberty,  or  the  meno- 
pause. 

Symptoms. — The  eruption  always  makes  its  appearance  upon 
the  face,  as  the  nose,  chin,  cheeks  or  brow.  The  symptoms  may 
be  divided  into  three  stages  or  varieties.  In  the  first,  there  is 
simply  dilatation  of  the  small  vessels  and  capillaries,  with  new 
formation    of  vessels.      In  the   second,   redness   of    the   surface 


46  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

makes  its  appearance,  which  is  at  first  congestive  and  transitory, 
but  finally  becomes  permanent,  and  slight  desquamation  takes 
place.  The  skin  has  a  dusky  tint,  especially  after  meals  and  in 
cold  weather.  In  the  third  variety,  owing  to  cell  infiltration  and 
the  new  formation  of  connective  tissue,  hypertrophy  of  the 
tissues  of  the  skin  is  apparent,  and  the  skin  has  a  thickened  and 
coarse  appearance. 

Hebra  describes  the  brandy-face  and  the  wine-face.  The 
brandy-face  is  frequently  confined  to  the  nose,  where  it  dilates 
the  blood-vessels,  and  the  skin  between  is  healthy.  The  wine- 
face  is  of  a  dark  red  color,  and  the  skin  has  a  solid  redness,  and 
the  whole  face  has  a  bloated  appearance. 

Treatment. — Constitutional  treatment  is  very  important.  In 
cases  of  debility,  a  generous  diet,  tonics,  especially  arsenic,  are 
indicated.  The  local  treatment  is  even  more  important.  If  the 
blood  vessels  are  very  much  dilated,  they  should  be  slit  open,  or 
punctured  at  each  end,  and  touched  with  caustic,  or  they  may 
be  obliterated  by  electrolysis.  The  finest  cambric  needle,  at- 
tached to  the  negative  pole  of  the  galvanic  battery,  is  inserted 
into  the  lumen  of  the  vessel,  or  perpendicular  to  the  vessel  at 
several  points  if  a  long  one,  and  six  to  ten  cells  turned  on,  until 
the  proper  electrolytic  action  is  developed. 

PRESCRIPTIONS  FOR  COPPER=NOSE. 

JH     Hy  drargy  ri 5  i  v. 

Terebinth  commun 5ij- 

Cerse  flavae 5iij- 

Em  pi.  plumbi Siss. — M. 

Ft.    unguent.     (See  Acne  Vulgaris). 

ADDISON'S  DISEASE. 

Addison's  disease  is  an  affection  of  the  suprarenal  capsules. 
It  is  sometimes  called  the  bronzed  skin  disease. 

Symptoms. — Extreme  languor,  muscles  flabby,  the  pulse 
feeble,  indigestion,  anorexia  and  nausea,  sometimes  vomiting 
after  eating.  The  skin  is  jrigmented,  and  presents  the  color  of 
a  mulatto. 


AFTER    PAINS.  47 

Prognosis. — It  is  an  incurable  disease.  Its  duration  varies 
from  one  to  live  years. 

Treatment. — Sirup  of  the  iodide  of  iron,  cod-liver  oil,  chlor- 
ide of  calcium,  ojuinia,  and  arsenic  may  he  tried.  Faradism  and 
galvanism  have  been  proposed  by  Dr.  Rockwell. 

Addison's  disease  is  thought  to  be  tuberculosis  of  the  supra- 
renal bodies. 

AFTERPAINS. 

The  contractions  of  the  uterus  in  the  first  few  days  after 
the  birth  of  the  child  are  the  causes  of  what  are  termed  after- 
pains.  They  may  last  four  days,  and  are  more  pronounced  in 
multipara  than  in  primiparse.  They  are  to  be  regarded  as  a 
normal  and  favorable  event.  Where  the  uterus  has  been  over- 
distended,  as  in  twin  pregnancies  and  hydramnios,  the  after-pains 
are  especially  severe.  Suckling  the  infant  produces  reflex  con- 
tractions of  a  somewhat  severe  character. 

PRESCRIPTIONS  FOR  AFTER=PAINS. 

Yfc     Morphinee  acetatis gr.  i. 

Extracti  digitalis  fiuidi 2TTj . 

Spiriti  Mindereri  3j  — M. 

Sig. :     One  dose.     Repeat  if  necessary. 

j&     Extracti  ergotse  fiuidi oiij- 

Extracti  digitalis  fiuidi ZTTxxiv. 

Quininse  Sulphatis gr.  xxiv. — M. 

Sig.:  Fifteen  drops  three  times  daily.  (To  aid  the  process  of 
involution).  The  quinine  may  be  given  in  capsules  in  gr.  ii.  doses, 
if  preferred.  —Sloan  Maternity. 

Jfc     Chloral  Hydratis gr.  xv. 

Sig.:     One  dose.     May  be  repeated  if  necessary. 

J&     Camphorae  gr.  x. 

Morphinee gr.  h — M. 

Sig. :     One  dose.  — Bartholow. 


48  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

AGALACTIA. 

Agalactia  is  imperfect  lactation. 

PRESCRIPTIONS  FOR  AGALACTIA. 

|&     Extracti  pilocarpi  fhiidi 5  ij . 

Sig. :  A  teaspoonful  two  or  three  times  daily.  — Bartholow. 

|Jr     Decocti  gossypii  Oj. 

Sig.:   A  wineglassful  every  half  hour. — Phillips. 

AGUE.     (See  Intermittent  Fever). 

AGUE=CAKE. 

Is  an  enlargement  of  the  spleen  from  malaria. 

Treatment. — Besides  quinine  in  ordinary  doses,  there  is  no 
remedy  more  efficacious  than  the  ointment  of  the  red  iodide  of 
mercury  rubbed  in  daily  oyer  the  splenic  region  in  the  sunshine, 
until  soreness  of  the  shin  compels  a  suspension. — Bartholow. 

ALBUMINURIA. 

Is  simply  albumen  in  the  urine.  It  is  not  a  disease,  but  a 
symptom.  The  existence  of  albuminuria  is  not  proof  positive  of 
kidney  disease.  Albumen  may  be  found  in  the  urine  iu  the 
course  of  a  great  many  diseases.  It  is  frequently  found  in  the 
urine  of  persons  who  are  apparently  in  perfect  health.  As  a 
rule,  albumen  found  in  the  urine  denotes  some  kidney  change. 

PRESCRIPTIONS  FOR  ALBUMINURIA. 

|fc     Sodii  iodidi gr.  xv. 

Sodii  phosphatis 5ss. 

Sodii  chloridi oiij- 

Aquae — q.  s. — add  ft.  sol — M. 

Sig. :  To  be  taken  in  the  course  of  the  twenty-four  hours. 

— Semmola. 


ALBINISM.  49 

{&     Olei  erigerontis  Sss. 

Sig. :    Five  drops  on  a  lump  of  sugar  every  three  or  four  hours. 
(In  the  chronic  forms).  — Bartholow. 

{&     Auri  et  sodii  chloridi gr.  iij. 

Hydrargyri  chloridi  corrosivi gr.  v. 

Extracti  gentiance q.s. — M. 

Ft.  massa  et  in  pil.  no.  lx.  div. 

Sig. :  One  pill  morning  and  evening.  — Bartholow. 

]$-     Acidi  gallici oi-ij • 

Acidi  sulphurici  diluti 5ss. 

Tincturee  lupuli 5j  • 

Infusi  lupuli — add  Syj. — M. 

Sig.:  A  tablespoonful  thrice  a  day.     (If  urine  is  smoky). 

— Aitken. 
Jfc     Misturse  ferri  et  ammonii  acetatis.Syj. 
(U.  S.  P.) 
Sig.:  Two  teaspoonfuls,  well  diluted,  thrice  daily.        — Basham. 

{&     Ferri  sulphatis gr.  xv. 

Magnesii  sulphatis  Sij- 

Potassii  bicarbonatis oiij- 

Infusi  buchu Sviij. — M. 

Sig.:     A  tablespoonful  once  or  twice  a  day  in  a  tumblerful  01 
water.      (When  constipation  exists).  — Fothergill. 

The  skim-milk  treatment  of  albuminuria  is  a  success. 

— Donkin. 

The  butter-milk  cure  may  be  substituted  for  the  milk-cure 
in  cases  of  stomach  disease  and  in  albuminuria. — Bartholow. 

ALBINISM. 

Is  defective  pigmentation  in  the  skin,  hair  and  eyes.  The 
pigment  of  the  skin  is  in  the  mucous  layer  of  the  epidermis.  In 
this  condition  there  is  congenital  absence  of  the  coloring  matter, 
and  the  skin  is  milky  white,  the  hair  white,  long,  fine,  and  silky, 
and  the  iris  is  rose  colored,  the  pupil  being  red. 

There  is  usually  intolerance  of  light  and  the  Albino  walks 
with  the  head  downwards. 

This  deformity  is  met  with  in  all  races,  but  it  occurs  most 
among  the  negroes  of  the  South. 

It  demands  no  treatment. 


50  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ALCOHOLISM. 

Is  the  physical  and  mental  changes  induced  by  alcohol.  It 
may  be  acute  or  chronic. 

Mania  a  potu  is  acute  alcholic  delirium. 

Delirium  tremens  is  a  delirium  with  trembling  occurring  in 
the  course  of  chronic  alcoholism. 

Symptoms, — The  symptoms  are  familiar  to  all.  In  the 
chronic  form  the  appetite  declines,  the  stomach  becomes  intoler- 
ant of  food,  and  vomiting  occurs.  The  old  alcoholic  suffers  in 
the  early  morning  before  the  morning  dram.  He  strains  and 
retches,  and  after  great  anguish,  brings  up  only  some  glairy 
mucus  and  a  little  greenish  matter.  His  memory  grows  weaker, 
his  moral  sense  is  blunted,  he  becomes  morose  and  irritable,  has 
headache,  ringing  in  the  ears,  attacks  of  dizziness  or  vertigo,  his 
vision  grows  dull,  numbness,  tingling,  trembling,  and  paresis  of 
muscles  occur.  He  also  becomes  wakeful  and  nervous.  Liver 
and  kidney  trouble  supervene  with  ascites  and  puniness  of  face. 

Treatment. — Withdraw  the  stimulant,  be  careful  with  his 
diet,  give  tonics  such  as  quinine,  tincture  of  mix  vomica,  etc. 

PRESCRIPTIONS  FOR  ALCOHOLISM. 

|fc     Potasii  bromidi 3j- 

Sig. :     One  dose.     Repeat  every  four  to  six  hours  if  necessary. 
(For  the  horrors.)  — Bartholow. 

Jfc    Tincturae  gentianae  comp 

Tincturae  calumbae  comp — aa 5ij- 

Tincturse  nucis  vomicae oiss. — M. 

Sig.:     A  dessertspoonful  before  each  meal.  — Loomis. 

Jfc     Strychniae  sulphatis gr.  j. 

Aqua  font Sj—  M. 

Sig.:     Five    minims    increased    cautiously    to    twenty    minims 
hypodermically  twice  daily.     (In  both  acute  and  chronic  forms.) 

— Dobronravoff. 

J$r     Sol.  nitro-glycerine  (1  per  cent)..3ij- 
Sig.:     One  drop  every  two  hours.  (In  acute  form,  with  cerebral 
anaemia  and  intense  depression.)  — Van  Goidtsnoven. 


ALCOHOLISM ALOPECIA.  51 

{&     Spiriti  ammonii  aromatici 5ij- 

Tincturse  camphorse  oiss. 

Tincturse  hyoscy ami 3iiss. 

Spiriti  lavandulse  comp.  q.  s.  addSij. — M. 
Sig. :     A  teaspoonful  every  hour  until  relieved.     Then  give 

|fc     Pulveris  capsici gr.  ij. 

Quininse   sulphatis gr.  iij. — M. 

Ft.  pulv.  no.  i. 

Sig. :     To  be  taken  before  each  meal  for  several  days.      — Aitken. 

{&     Extracti  lupulinse  fluidi. 

Tincturse  capsici — aa 5j  • — M. 

Sig.:     One   or  two  teaspoonfuls  as   necessary.     (Best  substitute 
for  alcoholic  stimulants.)  — Bartholow. 

Jfc     Liquoris  potassii   arsenitis Sss. — M. 

Sig.:     A   half  drop    every   half  hour,  for    six    or   eight    doses. 
(Vomiting  of  alcoholics.)  — A.  A.  Smith. 

Jfc     Sodii  bromidi ..Sss. 

Chloral   hydratis oiiss. 

Syrupi   aurantii    cort Sss. 

Aquse,  ad Siv. — M. 

Sig.:      A    tablespoonful    at  night.    Repeat   if  necessary.     (For 
sleeplessness.)  — Aitken. 

Give  opium  and  chloral  very  cautiously  to  old  alcoholics. 
For  the  "alcoholic  paralysis,"  or  partial  paraplegia  use  fara- 
dism  and  galvanism. 

ALOPECIA. 

Is  baldness  or  loss  of  hair  or  defective  growth.  It  may  be 
congenital  or  acquired.  It  is  a  common  thing  for  children  to  be 
born  with  very  little  hair,  but  it  soon  begins  to  grow;  in  rare 
cases  it  never  makes  its  appearance. 

Congenital  alopecia  has  also  been  observed  in  the  lower 
animals,  especially  in  a  race  of  horses  found  in  Little  Thibet,  on 
whose  hide  not  a  trace  of  hair  can  be  discovered;  also  in  a  race 
of  African  dogs  and  hogs. 

Treatment. — Is  both  constitutional  and  local.  Cod-liver  oil 
and  tonics,  especially  nerve  tonics,  as  strychnia,  phosphorus,  and 
above  all  arsenic  are  usually  indicated. 

The  local  treatment  resolves  itself  into  the  use  of  reme- 
dies to  stimulate  the  hair  follicles, 


52  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  ALOPECIA. 

^     Tinoturse  canthardis Sss. 

Olei  ricini Siv. — M. 

Sig. :     Rub  well   into   the    roots  of  the  hair  night  and  morning. 

— Waring. 

|fc     Tincturse  cantharidis 5iss. 

Tincturse  capisici Ht.xx. 

Glycerinse Sss. 

Spirit!  odoratse — add . Syj. — M. 

Sig. :     Apply     to   head    two    or  three  times  daily.  —  Gross 

J&     Hydrargyri  perchloridi gr.  xij. 

Glycerini 5  vj . 

Spiriti  rectificati Siij. 

Aquae  destillatae — add Syj. 

Olei  rosse ZTT.j.— M. 

Ft.  lotio.     Apply   to  scalp  night  and  morning.  — Anderson. 

Jfc     Liquoris  carhonis  detergentis Sj. 

Glycerini  ( Price) 5 vj  • 

Aquse  destillatse Siv. — M. 

Sig.:     Sponge   the    scalp    night  and  morning.  — Anderson. 

JJr     Pulveris   cantharidis 5j 

Glycerini  (Price) 5j  • 

Unguenti  simplicis 5vj. — M. 

Sig.:     Apply  firmly  to  the  scalp  night  and  morning. 

— Anderson. 

|fc     Tincturse  macis „..5iss. 

Olei   olivse — add 5ij. — M. 

Sig.:     Apply  two  or  three  times  daily  to  affected  spots. 

— Hebra. 

Jfc-    Quininse  sulphatis oiss. 

Spiriti  vini  rectificati Siv. 

Tincturse  capsici 

Tincturse  cantharidis 

Spiriti  ammonii  aromatici — aa...Sss. 

Glycerini Siv. 

Aquse  q.  s. — add Oj. — M. 

Sig.:     Apply  locally.  — Brinton. 

Alopecia  depending  on  Syphilis,  Eczema  and  Psoriasis  may 
be  cured  by  the  proper  treatment  for  those  affections. 

Pilocarpus  is  the  most  efficient  remedy  for  alopecia  which 
we  possess. — Bartholow. 


AMAUROSIS AMENORKIKEA.  58 

Jfc     Extracti  pilocarpi  fluidi  Sj. 

Tincturse  cantharidis Sss. 

Linimenti  saponis  Siiss. — M. 

Sig.:     The   scalp   must   be    well  rubbed  with  this  lotion  daily. 

— Bartholow. 

AMAUROSIS.     (Functional.) 

Amaurosis  is  partial  or  complete  blindness.  Amblyopia  is 
impairment  of  vision.  Since  the  ophthalmoscope  has  come  into 
use,  making  the  interior  of  the  globe  as  accessible  to  our  sight 
as  the  exterior,  these  terms  have  fallen  into  comparative  disuse, 
and  are  used  to  designate  conditions  whose  pathology  is  not 
known  (functional). 

Causes. — 1.  Traumatic.  2.  By  lightning.  3.  Hemorrhage. 
4.  Toxic,  such  as  lead,  osmic  acid,  silver  and  mercury,  quinine, 
and  salicylic  acid.  Alcohol  and  tobacco,  which  excite  a  peculiar 
partial  neuritis,  may  cause  amaurosis  or  amblyopia.  5.  Uraemic. 
6.  Diabetic.     7.  Hysterical.     8.  Migraine.     9.  Reflex. 

Treatment, — Depends  on  the  cause.  For  toxic  causes,  suita- 
ble antidotes  and  abstinence  suggest  themselves.  Galvanization 
and  faradization  may  be  tried.  Amaurosis  of  a  functional  kind, 
from  lead,  tobacco  and  alcohol,  may  be  cured  by  strychnine. 

PRESCRIPTIONS  FOR  AMAUROSIS. 

{J-     Strychnise  sulphatis ,...gr.  j. 

Alcoholis 5j  • 

Aquse  destillatse — ad  Siv. — M. 

Sig.:   A  teaspoonful  thrice  daily  before  meals.  — Nagel. 

According  to  Coursserant,  there  is  no  remedy  comparable 
to  pilocarpine  in  the  amblyopia  of  alcoholism  and  of  tobacco 
abuse.     Dose,  gr.  iVgr.  ss. 

AMENORRHEA. 

Is  abnormal  suppression  or  absence  of  the  menses.  Primary 
amenorrhea,  called  also  emansio  mensium,  is  where  menstrua- 
tion has  never  occurred.  Secondary  or  accidental  amenorrhea 
has  been  called  suppressio  mensium. 

Causes. — Amenorrhea  is,  more  frequently  than  to  any  other 
cause,  due  to  anaemia  of  the  ovaries,  consecutive  to  chlorosis  or 


54  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

general  anaeinia,  and  dysnienorrhoea  may  depend,  in  one  of  its 
forms,  at  least,  upon  the  same  condition  of  the  blood. — Bartholow. 

When  the  menses  are  absent  at  puberty  it  may  be  due  to 
atresia  of  the  uterus,  vagina  or  vulva,  or  to  bad  hygienic  sur- 
roundings, or  to  overwork  at  school.  After  the  menses  have 
become  established,  they  may  cease  entirely  from  impoverish- 
ment of  the  blood,  from  debility  resulting  froru  a  chronic  disease 
or  following  an  acute  illness. 

Anaemia,  chlorosis,  Bright's  disease,  diabetes,  cancerous  and 
malarial  cachexia,  and  pulmonary  tuberculosis  are  all  potent  in 
producing  amenorrhoea. 

Menstruation  may  be  suppressed  from  some  sudden  emotion, 
anxiety,  and  from  taking  cold. 

Symptoms. — Abscence  of  the  monthly  flow  is  of  course  the 
chief  sign.  There  may  be  headache,  fever,  pain  in  the  chest  and 
pelvis,  acne,  eczema,  herpes,  and  urticaria. 

Science  has  on  record  some  curious  examples  what  may  be 
called  substituted  secretions. 

Jones  reports  the  case  of  a  young  woman  in  whom  menstru- 
ation was  checked  apparently  from  sudden  chilling,  who  then 
suffered  from  amenorrhoea,  and  for  five  years  had,  instead  of  the 
menstrual  flow,  an  abundant  flow  of  milk  from  the  breasts  which 
lasted  for  thirty- six  hours.  Periodical  diarrhoea  for  three  days, 
-  or  leucorrhoea  may  replace  the  normal  flow  (Pozzi). 

Haemoptysis  (spitting  blood),  haeruatemesis  (vomiting  blood), 
epistaxis  (nose  bleed),  and  rectal  hemorrhages  may  replace  the 
normal  flow,  and  this  is  known  as  vicarious  or  ectopic  menstru- 
ation. 

Treatment. — Depends  on  the  cause.  Where  atresia  exists, 
an  operation  is  necessary.  If  the  amenorrhcea  be  due  to  bad 
hygiene,  or  over- study,  or  poor  health,  correct  these  conditions. 
Pozzi  says  that  it  is  a  mistake  to  suppose  that  amenorrhoea  calls 
for  special  medication  supposed  to  have  an  elective  action  upon 
the  uterine  mucous  membrane.  Iron  and  aloes,  and  saline 
purgatives  may  be  given  in  certain  cases.  Permanganate  of  po- 
tassium is  said  to  be  almost  a  specific.  Apiol  is  sometimes  of 
service.  Mustard  foot  baths  and  mustard  plasters  to  the  thighs 
and  l^pogastriuni,  and  the  hot  sitz-bath  are  important  aids. 


AMENORRHEA.  55 

Tonics  and  good  food  must  be  given.  Electricity  (faradic) 
with  one  pole  npon  the  lumbar  region  and  the  other  externally 
over  the  site  of  the  uterus  has  given  good  results  (Rockwell). 

During  pregnancy  and  lactation  menstruation  ceases;  it  re- 
turns only  when  the  excess  of  nutritive  material  is  no  longer 
required  for  these  purposes. 

Menstruation  may  then  be  considered  a  safety  valve;  its 
absence  indicates  a  lowering  of  nutrition  when  it  is  not  the  re- 
sult of  pregnancy. 

PRESCRIPTIONS  FOR  AMENORRHEA. 

Jfc     Tinctune  aconiti  radicis 5ss. 

Sig. :     One  drop  every  hour.     (When  checked  by  cold.) — Ringer. 

Jfc     Potassii  permanganatis 5j 

Ft.  in  no.  xxx  pellets. 
Sig.:     One  three  times  daily  after  meals  followed  by  a  glass  of 
water.     (Begin  one  week  before  the  expected  period.)      — Bartholow. 

{&     Auri  et  sodii  chloridi gr.  iij 

Aqua? 5  viij . — M. 

Sig.:     A  teaspoonful  after  meals.  — Bartholow. 

JJr     Extracti  hydropiperis  fluidi 5iv. 

Sig.:  Thirty  minims  four  times  a  day,  for  a  week  before  the 
menses  ought  to  appear,  when  due  to  functional  inactivity  or  torpor 
of  the  uterine  system. 

Bartholow  can  confirm  the  statement  of  Eberle,  who  reports 
that  "  with  no  other  remedy  or  mode  of  treatment  has  he  been 
so  successful  as  with  this,"  in  amenorrhcea. 

jfc     Apiol  (parsley-camphor) 3j. 

Sig.:  Six  drops  morning  and  evening  for  five  days  before  the 
expected  menstrual  period.  (When  torpor  of  the  ovaries  and  uterus 
exist.)  — Biddle. 

Jfc    TerebinthinaB  albas 

Pulveris  aloes 

Ferri  sulphatis  exsic — aa gr.  xx. — M. 

Ft.  massa  et  in  pil.  no.  xx  div. 

Sig. :     One  thrice  daily.  — Parvin. 


56  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

|fc     Extracti  aloes  aq 3j- 

Ferri  sulphatis  exsic 5ij • 

Asafcetidae oiv. — M. 

Ft.    massa  et  in  pil.  no.  100  div. 

Sig. :     One  pill  after  each  meal,  gradually  increased  to  three. 

— Goodell. 

J&     Tincturse  ferri  chloridi 5iij. 

Tincturse  cantharidis 5j • 

Tincturse  guaiaci  ammonii Siss. 

Tincturse  aloes Sss. 

Syrupi — q.  s.,  add Svj. — M. 

Sig. :    A  teaspoonful  thrice  daily.  — Dewees. 

ANEMIA. 

Is  a  ruorbid  condition  from  diminution  of  blood  or  its  nutri- 
tive constituents.  Anaemia  may  be  only  a  symptom  of  some 
other  disease.  It  may  be  acute  or  chronic.  Acute  anaemia  is 
the  result  of  sudden  and  excessive  loss  of  blood,  as  from  wounds 
of  arteries,  post  partum  haemorrhage,  and  fevers.  Chronic  anae- 
mia may  result  from  many  forms  of  chronic  diseases,  as  Bright's 
disease,  malignant  growths,  tuberculosis,  etc.  Anaemia  may 
also  be  caused  by  defective  assimilation,  an  insufficient  supply  of 
food,  frequent  repetition  of  the  sexual  orgasm,  profuse  menstrual 
flow,  prolonged  lactation,  pregnancy,  poison  in  the  blood  from 
lead,  malaria,  etc. 

Symptoms. — The  patient  is  weak  and  pale.  His  lips  and 
tongue  have  lost  their  red  color.  The  eye  is  pearly.  His  pulse 
is  feeble,  but  generally  accelerated.  The  appetite  is  deficient  or 
depraved.  The  bowels  are  apt  to  be  costive.  Exercise  induces 
great  fatigue,  shortness  of  breath  and  palpitation  (DaCosta). 
There  is  mental  depression.  The  hands  and  feet  are  always 
cold.  Anaemic  females  complain  of  a  pain  in  the  left  side  and  a 
burning  sensation  on  top  of  the  head.  Over  the  jugulars, 
particularly  the  right,  there  is  heard  a  continuous  venous  hum 
(Loomis). 

Prognosis. — Depends  upon  the  cause  of  the  anaemia.  It  is 
usually  favorable. 


ANJEMIA.  57 

Treatment. — The  causes  of  anaemia  are  to  be  ascertained, 
and,  if  possible,  removed.  Good  food  is  the  first  requisite.  The 
appetite  and  digestion  should  be  promoted  by  quinia  and  other 
tonic  remedies.  Exercise  in  the  open  air,  daily  sponging  of  the 
body,  and  sea-bathing  have  a  favorable  influence.  Iron  is  the  one 
drug  that  best  combats  anaemia  (Loomis).  It  should  be  given 
after  meals.  Arsenic  is  another  remedy  often  of  much  efficacy 
in  the  treatment  of  anaemia  (Flint).  It  should  be  given  in 
small  doses  for  a  long  time.  Loomis  says  that  alcohol  is  food  to 
aneemic  patients,  and  that  Burgundy,  Madeira,  and  rich  wines 
are  to  be  preferred;  but  malt  liquors  are  often  more  beneficial. 
Cod-liver  oil,  and  the  syrup  of  the  lacto- phosphate  of  lime  are 
of  great  service.  The  physician  should  encourage  the  patient. 
Central  galvanization,  and  general  faradization  are  of  use  to 
stimulate  the  functions  of  organic  life     (Bartholow). 

PRESCRIPTIONS  FOR  ANEMIA. 

J&     Quininse  sulphatis gr.  xx. 

Ferri  sulphatis  exsiccat gr.  xl. 

Stryehnise  sulphatis gr.  ss. — M. 

Ft.  massa  et  in  pil  no  xx.  div. 
Sig. :     One  pill  thrice  daily.  — Bartholow. 

J£     Tincturse  ferri  chloridi 5iv. 

Acidi  phosphorici  diluti 5yj. 

Spiriti  limonis 3ij . 

Syrupi — q.  s.  add Svj. — M. 

Sig. :    A  dessertspoonful  in  water  after  meals.  — Goodell. 

|fc     Hydrargyri  chloridi  corrosivi gr.  i-ij 

Liquoris  arsenici  chloridi 5j 

Tincturse  ferri  chloridi  3iv. 

Acidi  hydrochlorici  diluti  5iv. 

Syrupi Siij. 

Aquae — add Svj. — M. 

Sig.:     A  dessertspoonful  in  a  wineglassful  of  water  after  meals. 

—A.  H.  Smith. 

|fc     Ferri  sulphatis  exsiccat 

Potassii  carbonatis  aa 5j  • 

Syrupi — q.  s.,  ut.  ft.  massa — M. 

Ft.  massa  et  in  pil  no.  xxiv.  div. 
Sig.:   One  pill  after  meals.  — Bland. 


58  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Liquoris   potassii   arsenitis Sss. 

Tincturse  gentianse  composite §ivss. — M. 

Sig.:     Half  teaspoonful  after  each  meal.     (Small  doses  of  iron 
may  be  given  with  the  above). 

R     Syrupi  calcii  lacto-phosphatis Siv. 

Liquoris  potassii  arsenitis 5j — M. 

Sig. :    A  teaspoonful  three  times  daily.     (In  anaemia  of  lactation 
and  of  suppuration).  — Bartholow. 

ANEURISM. 

Is  a  tumor,  or  sac,  containing  blood  which  communicates 
with  the  interior  of  an  artery.  Its  walls  are  formed  of  the  coats 
of  an  artery. 

Causes. — The  aorta  is  the  favorite  site  of  aneurisms,  because 
it  is  subjected  to  great  strain.  Powerful,  muscular  effort,  syph- 
ilis, chronic  arteritis,  are  the  chief  causes.  Degeneration  of  the 
vessel  walls,  overaction  of  the  heart,  as  in  hypertrophy,  gout, 
rheumatism  and  alcohol  may  cause  aneurism.  Exciting  causes 
are:  external  wounds,  fractures  and  dislocations,  and  sprains.  It 
occurs  most  frequently  between  30  and  50. 

Symptoms. — The  earliest  symptom  of  thoracic  aneurism  is 
pain.  This  may  be  a  fixed  pain,  almost  constant,  and  felt  in  one 
spot  under  the  sternum,  lancinating  and  tensive  in  character, 
shooting  up  to  the  neck  and  shoulders,  down  the  arm  to  the 
elbows;  or  it  is  felt  in  the  back  and  shoots  around  the  chest.  At 
times  the  attacks  of  pain  are  most  severe,  and  demand  the 
use  of  active  anodynes  (Bartholow).  If  erosion  of  vertebra?, 
sternum,  or  ribs  occurs,  there  is  a  peculiar,  constant  "boring" 
pain.  Pressure  of  the  aneurism  on  the  recurrent  laryngeal 
nerves  causes  dyspncea  and  the  voice  becomes  husky.  Pressure 
on  the  pneumogastric  may  cause  vomiting  and  pyrosis.  Pressure 
on  the  pulmonary  plexus  gives  rise  to  a  harsh,  metallic,  "brassy" 
cough.  Pressure  on  the  cervical  sympathetic  causes  contraction 
of  the  pupil  on  the  affected  side,  and  irritation  causes  dilation 
of  the  pupil  (Loomis).  Pressure  on  the  external  jugular  causes 
the  head  and  neck  to  become  turgid  on  that  side.  Pressure  on 
the  trachea  causes   dyspnoea  and  a  stridulous  cough  (with  no 


.       ANEURISM.  59 

expectoration)  like  a  nervous  cough.      Pressure  on  the  thoracic 
duct  will  cause  mal- assimilation,  wasting  and  inanition. 

The  symptoms  of  aneurisms  in  general  are:  1.  Expansile 
pulsation.  2.  Pressure  on  the  artery  above  destroys  the  pulsa- 
tion and  diminishes  the  size  of  the  aneurism.  3.  Aneurismal 
bruit — a  rasping  sound,  like  sawing  wood.  4.  Pain,  due  to 
pressure  on  the  sensory  nerves.  The  following  tumors  may  be 
mistaken  for  aneurisms:  1.  Pulsating  sarcoma  and  soft  vascular 
carcinoma.  2.  Abscess  lying  on  an  artery.  3.  Enlarged  glands 
lying  on  an  artery. 

A  clean  hypodermic  needle  may  be  thrust  into  the  sac  or 
tumor  to  make  the  diagnosis  positive  (Bartholow). 

Prognosis. — Unfavorable. 

Treatment. — Is  both  medical  and  surgical.  Absolute  rest 
is  the  first  essential.  The  diet  must  be  nutritive  but  unstimulat- 
ing.  Iodide  of  potassium  and  ergot  are  the  only  drugs  that  have 
stood  the  test  of  time  (Loomis).  Morphine  must  be  given  for 
the  pain.  For  cases  amenable  to  surgical  treatment,  see  works 
on  surgery. 

PRESCRIPTIONS  FOR  ANEURISM. 

J&     Barii  chloridi gr.  xvij. 

Aqua? Sj . — M. 

Sig. :    Six  drops   in   a   tablespoonful  of  water   three  times  daily 
after  meals,  for  four  or  five  months.  — Flint. 

{&     Potassii  iodidi (grs.  xv. — 5ss.) 

Three  or  four  times  a  day.     (This  relieves  pain  and  promotes 
coagulation  of  blood  in  the  sac).  — Bartholow. 

JJr     Antipyrin 3iss. 

Syrupi  tolutan Siss. 

Aquse — add Siij . — M. 

Sig.:  A   tablespoonful  at  intervals  of  one   to   four  hours   until 
relieved.    (For  cardiac  pain).  — See. 

Jfy     Potassii  iodidi Sss. 

Syrupi  simplicis 5j • 

Aquae  menthre  piperita? — ad Siij. — M. 

Sig.:     A  teaspoonful   three  times   daily,  gradually  increased  to 
three  teaspoonfuls,   but    diminished   on  any  increase  of  pulse   rate. 

— Balfour. 


60  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ANASARCA. 

Is  not  a  disease  but  a  symptom.  It  is  a  universal  accu- 
mulation of  serous  fluid  in  the  areolar  tissue.  CEdema  is  a 
localized  collection  of  serum  in  the  same  tissue.  These  terms, 
therefore,  differ  in  nothing  but  extent.  (For  treatment  of  these 
conditions  see  dropsy.) 

ANGINA  PECTORIS. 

Is  a  neurosis  of  the  heart  characterized  by  pain,  usually  in- 
tense, burning,  tearing  or  lancinating  in  character,  in  the  pre- 
cordial region,  radiating  into  the  back,  left  shoulder  and  down 
the  left  arm,  and  accompanied  by  a  feeling  of  constriction  of  the 
chest,  and  a  strong  sense  of  impending  death.  It  is  frequently 
associated  with  organic  disease  of  the  heart  (Bartholow  and 
Loomis). 

Treatment. — The  affection  is  paroxysmal.  There  is  a  sud- 
den indescribable  anguish,  or  "heart-pang"  with  a  sense  of 
suffocation,  pale  face,  cold  sweat,  arterial  tension  high,  action  of 
heart  disturbed.  The  paroxysms  may  last  a  few  seconds  only, 
or  for  hours,  or  even  days  (Bartholow  and  Loomis). 

Prognosis. — Unfavorable. 

Treatment. — All  causes  of  disturbance  of  the  heart  action, 
as  tobacco -smoking,  alcohol,  over -ingestion  of  food,  and  excite- 
ment must  be  removed. 

Five  drops  of  nitrite  of  amyl  should  be  inhaled  from  a 
handkerchief  during  the  paroxysm. 

Morphine  hypodermically  for  pain. 

Nitro- glycerine  to  prevent  the  attacks.  Fowler's  solution, 
cod-liver  oil  and  the  hypophosphites  should  be  given.  Electri- 
zation has  been  found  useful  (Bartholow,  Loomis  and  Flint). 

PRESCRIPTIONS  FOR  ANGINA  PECTORIS. 

1^     Liquoris  potassii  arsenitis Sj- 

Sig. :     Ten  drops  three  times  a  day  after  meals.     (Given  during 
the  interval.)  — Bartholow. 

JJr     Amyl  nitritis oij- 

Sig.:     Two  to  ten  drops    on  handkerchief  for  inhalation. 

-  Brunton. 


ANTHRAX.  61 

jjr     Sol.  nitro-glycerine  (1  per  cent.). .  5ss. 
Sig. :     One-half  to   two    drops  internally.     (When  pallor  of  face 
exists.)  — Pepper. 

|&     Antipyrin 5j- 

Syrupi  tolutan 5j  • 

A  qua? — add Sij- — M. 

Sig.:     A  tablespoonful  at  intervals  of  one  to  four  hours   until 
relieved.  — See. 

ANTHRAX. 

Commonly  known  as  Carbuncle  is  a  circumscribed, 
indurated,  inflammation  of  the  skin  and  cellular  tissues.  It  is 
larger  than  a  boil,  and  forms  on  the  back  or  neck,  sometimes  on 
the  face  and  buttock.  Carbuncle  is  a  far  more  serious  affection 
than  a  boil,  and  occurs  generally  in  men  over  45.  The  pain  is 
severe,  sometimes  intense;  of  a  heavy,  aching,  throbbing,  sting- 
ing, burning  character.  The  inflamed  area  shows  no  disposition 
to  become  accumulated  like  a  boil,  but  maintains  its  flat  and  very 
hard  character.  Little  ulcers  form  on  the  dusky  red  skin  which 
give  it  a  sieve-like  appearance,  so  numerous  are  the  openings, 
and  from  these  a  whitish  discharge  exudes.  Carbuncle,  attack- 
ing the  upper  lip,  is  found  to  be  an  extremely  fatal  form  of  the 
disease,  and  kills  by  the  onset  of  pyaemia  (Flint  and  Anderson). 

Causes. — Poisonous,  or  irritating  materials  introduced  into 
the  skin;  j)rolonged  exposure  of  the  skin  to  a  scorching  heat; 
low  state  of  the  nervous  system  and  of  the  general  health,  pre- 
dispose to  their  occurrence  (Flint  and  Anderson). 

Treatment. — Begin  treatment  with  a  calomel  purge.  Give 
tonics,  such  as  quinine  and  iron  in  full  doses.  Morphine  may 
be  needed  to  quiet  pain.  Apply  heat  in  the  form  of  a  poultice 
with  acetate  of  lead  and  opium.  Paint  with  tincture  of  iodine. 
Mr.  O'Ferral  recommends  continued  pressure  by  applying  collo- 
dion to  the  inflamed  skin. 

Some  authorities  advise  incision. 


62  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  ANTHRAX. 

j&     Tincturse   ferri  chloridi  Sj. 

Potaseii  chlora  tis 5  j  • 

Glycerinse Sj. 

Aquas — add Siv. — M 

Sig.:     A  teaspoonful    in    a    wineglassful    of    water    every    two 
hours.  — Ringer. 

JJr     Lini  farinas 

Aquas  bullientis aa.    q.  s. 

M.  et   Ft.  cataplasma. 

Sig. :     Apply  as  hot  as  bearable  and  renew  when  necessary. 

— Rockwell. 

Faradization  will  hasten  snj^pnration. 

ANAESTHESIA. 

Is  loss  of  sensation.  It  is  of  various  degrees.  It  may  be 
complete,  or  partial,  or  a  mere  benumbing,  and  may  be  located 
in  any  part  of  the  body.  It  is  a  symptom  of  some  organic  or 
functional  disease  of  the  central  or  peripheral  nervous  system. 
Large  doses  of  Indian  hemp,  of  lead,  or  of  arsenic  may  cause 
anaesthesia.  We  see  it  in  hysteria,  syphilis  and  rheumatism,  and 
as  a  result  of  pressure  on  nerve  trunks,  and  of  disturbances  of 
the  circulation  and  abnormal  conditions  of  the  blood.  In  the 
parts  affected  with  anaesthesia  the  nutrition  is  less  active,  and 
there  is  a  feeling  of  numbness  and  the  temperature  lowered 
(Loomis). 

Treatment. — A  good  nutritious  diet  and  tonics.  For  the 
curable  cases  of  cutaneous  anaesthesia,  faradization  is  a  specific, 
if  any  remedy  can  be  said  to  be  a  specific  for  anything  (Rock- 
well).    Bartholow  recommends  strychnine. 

ANCHYLOSIS. 

Is  a  bony  or  fibrous  union  of  the  joint  ends  of  bones,  caus- 
ing immobility  of  the  joint.  Anchylosis  is  not  a  disease  of  itself, 
but  may  be  the  result  of  any  disease  or  injury  which  interferes 
with  the  normal  functions  and  motions  of  a  joint.  Anchylosis 
may  take  place  even  in  a  perfectly  healthy  joint  by  long-con- 


ANCHYLOSIS APHTILE.  63 

tinned  rest.  It  may  be  the  most  favorable  termination  that  can 
occur  in  many  diseases  and  accidents  of  the  joints. 

If  anchylosis  is  the  best  result  that  can  be  obtained,  then  the 
surgeon  should  see  that  the  elbow  is  anchylosed  at  a  right  angle, 
as  the  limb  will  be  more  useful,  and  the  knee  with  the  limb 
perfectly  straight  (Sayre  and  Bryant). 

Treatment. — If  the  anchylosis  be  fibrous,  we  resort  to 
forcible  movement  to  break  up  the  adhesions.  If  it  be  bony,  we 
divide  the  bone,  or  cut  out  a  wedge-shaped  portion.  It  may  be 
necessary  to  divide  the  tendons  before  applying  force.  After 
breaking  up  the  adhesions  in  the  fibrous  variety,  passive  motion 
may  be  resorted  to.  There  is  no  treatment  for  bony  anchylosis 
if  the  limb  is  already  in  the  best  position  (Bryant). 

APHTHA. 

Are  small  white  mucous  ulcers  of  the  mouth,  especially  of 
infants.  Aphthous,  follicular  and  croupous  stomatitis  are  other 
names  for  this  affection.  The  "aphthae,"  or  white  ulcers,  are 
found  on  the  internal  surface  of  the  lips,  cheeks,  tongue,  gums, 
etc.  The  smallest  of  these  patches  are  not  larger  than  a  pin's 
head. 

Causes. — Indigestion,  diarrhoea,  unripe  fruit,  candy  and  bad 
hygienic  surroundings. 

Symptoms. — The  constitutional  symptoms  are  slight.  The 
ulcers  are  painful;  the  child  is  fretful;  the  saliva  is  increased. 

Treatment. — Correct  any  intestinal  disturbance  that  may 
exist  with  small  doses  of  rhubarb  and  magnesia.  Wash  the 
mouth  with  a  weak  solution  of  glycerine  and  borax,  or  chlorate 
of  potash.  If  the  ulcers  are  slow  to  heal,  touch  them  lightly 
with  nitrate  of  silver.     Bathe  the  feet  in  warm  water. 

PRESCRIPTIONS  FOR  APHTHAE. 

Jfc     Bismuthi  subiritratis oj- 

Sig.:  Apply  dry  to  the  ulcer.  — Bartholow. 

JJr     Potassii  iodidi gr.  iv. 

Aqure 3  j  • — M . 

Sig. :     Apply  locally.  —Bartholow. 


64  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Jt    Mel.  boracis 5j. — M. 

Sig. :    Apply  to  patches  with  a  brush.  — Ringer. 

Jfc     Potassi  chloratis gr.  x. 

Aqua? Sj . — M. 

Sig.:  Apply  locally  several  times  daily.  — Brunton. 

{Jr     Sodii  salicylatis oiss. 

Aqua?  destillatse Sj- — M. 

Sig.:     Apply   five   or   six    times  daily.  — Hirtz. 

APHASIA. 

Is  inability  to  use  spoken  language  or  to  give  vocal  utter- 
ance to  ideas.  Where  the  memory  of  words  is  lost,  it  is  called 
amnesic  aphasia.  Where  the  power  of  expression  is  lost  and 
the  words  remembered,  it  is  called  ataxic  aj)nasia.  Aphasia  is 
really  not  a  disease,  but  a  symptom. 

Causes. — Aphasia  is  associated  with  a  number  of  intra- 
cranial lesions;  with  occlusion  either  by  thrombosis  or  embolism 
of  the  vessels;  with  cerebral  hemorrhage;  with  encephalitis, 
abscess,  meningitis,  tumors;  and  it  may  be  a  merely  mental  and 
moral  condition  (Bartholow). 

Treatment. — The  local  disease  on  which  the  aphasia  depends 
must  be  removed.  If  the  aphasia  persists  after  the  local  disease 
has  been  cured,  much  may  be  done  by  suitable  training. 

APOPLEXY. 

Is  sometimes  used  synonymously  with  cerebral  hemorrhage, 
but  incorrectly,  since  it  is  a  symptom  merely,  and  not  a  disease 
(Bartholow).  DaCosta  says  that  apoplexy  is  coma  coming  on 
rapidly,  in  consequence  of  the  compression  of  the  brain  by  ex- 
travasated  blood,  by  the  turgescence  of  the  vessels,  or  by  effusion 
of  serum. 

Loomis  limits  the  term  cerebral  apoplexy  to  non-traumatic 
hemorrhage  into  the  cerebral  substance  or  meninges. 

Causes. — Apojjlexy  is  rare  before  40  years  of  age.  Miliary 
aneurism,  periarteritis,  fatty,  atheromatous  and  fibroid  degenera- 
tion of  the  walls  of  the  vessels  are  causes  of  apoplexy,  or  cerebral 


APOPLEXY.  65 

hemorrhage.     Other  predisposing  causes  are:   gout,  rheumatism, 
syphilis,  chronic  Bright1*,  and  chronic  alcoholism. 

The  exciting  causes  are:  mental  excitement,  as  in  public 
speaking,  sexual  intercourse,  straining  at  stool,  and  violent  mus- 
cular exercises,  and  sudden  stopping  of  bleeding  piles  (Flint 
and  Loomis). 

Symptoms. — The  seizure  is  generally  sudden,  and  the  coma 
quickly  developed.  The  patient  falls  to  the  ground,  bereft  of 
all  consciousness.  In  other  instances,  the  apoplectic  seizure  is 
preceded  by  vertigo,  dizziness,  double  vision,  niuscse  volitantes, 
flushing  or  pallor  of  the  face,  nausea,  etc.  During  the  coma  the 
patient  lies  as  if  in  a  deep  sleep,  breathing  laboriously  and 
noisily,  and  each  snoring  inspiration  is  followed  by  a  puffing 
sound.  The  pulse  is  slow,  full,  and  at  times  irregular;  the  carotids 
throb  violently.  The  pupils  are  immovable,  and  either  con- 
tracted or  dilated,  and  the  eye  is  half  open.  In  severe  cases,  the 
breathing  becomes  very  irregular,  of  the  Cheyne- Stokes  variety. 

The  coma  may  last  from  a  few  hours  to  two,  three,  or  four 
days.  Hemiplegia  upon  the  side  opposite  to  the  hemorrhage  is 
one  of  the  most  constant  attendants  of  apoplexy,  especially  in 
the  aged  (Loomis).  The  eyes,  and  the  head  also,  frequently 
deviate  toward  the  side  affected  in  the  brain  and  from  the 
side  paralyzed;  this  movement  constitutes  a  means  of  diag- 
nosis between  cerebral  hemorrhage  and  other  causes  of  profound 
unconsciousness  (Bartholow). 

Treatment. — The  patient  should  be  placed  in  a  cool,  airy 
apartment.  Cold  should  be  applied  to  the  head,  and  heat  to 
the  feet.  Attention  must  be  directed  to  the  bladder.  An  active 
cathartic  should  be  given.  If  there  are  any  paralyzed  muscles, 
kneading,  rubbing  and  electricity  are  the  proper  remedies. 

PRESCRIPTIONS  FOR  APOPLEXY. 

{&     Olei  tiglii oj- 

Sig. :     Three  or  four  drops  may  be  given  at  once  and  repeated  in 
three  or  four  hours  if  free  purgation  be  not  produced,  — Flint. 


66  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

APPENDICITIS. 

Is  an  inflammation  of  the  appendix  vermiformis. 

Causes. — The  usual  causes  are  foreign  bodies,  such  as  in- 
spissated faeces,  fruit  seeds,  worms,  gall  stones,  catarrhal  condi- 
tion and  traumatism.  It  is  most  frequent  in  males  from  fifteen 
to  thirty  years  of  age. 

Symptoms. — At  first  there  are  slight  localized  pain  and  ten- 
derness in  the  right  iliac  region.  Later  on,  there  is  pain  in  the 
groin,  extending  down  the  course  of  the  anterior  crural  and 
through  the  hip.  The  slightest  attempt  at  palpation  gives  the 
patient  great  dread.     The  thigh  is  flexed  on  the  pelvis. 

The  following  symptoms  are  diagnostic  of  perforation  or 
acute  peritonitis:  a  sharp,  sudden,  intense  pain  in  the  iliac  fossa 
which  may  extend  to  the  navel,  liver,  or  into  the  back,  accom- 
panied by  nausea,  vomiting  and  chill.  Temperature  101°  to  102°. 

A  circumscribed  tumor  is  usually  detected  and  sometimes 
fluctuation. 

Prognosis. — When  perforation  has  occurred,  unfavorable. 

Treatment. — Antiphlogistic  measures  locally,  and  opium  in- 
ternally, but  according  to  Loomis,  it  is  best  to  make  an  explora- 
tory incision. 

ASCITES. 

Is  a  local  dropsy — an  accumulation  of  serum  in  the  perito- 
neal cavity.  The  amount  of  fluid  present  in  ascites  may  vary 
from  a  few  ounces  to  five  gallons  (Loomis).  It  is  usually. of  a 
light  straw  color.  Ascites  is  a  symptom,  or  an  effect  of  disease, 
not  strictly  a  disease  in  itself. 

Causes. — Ascites  may  be  the  result  of  disease  of  the  perito- 
neum, or  of  obstruction  in  the  main  trunk  of  the  portal  vein,  or 
in  the  branches  of  the  vessel  within  the  liver.  Cirrhosis,  throm- 
bosis, syphilitic  hepatitis,  abscess,  cancer,  and  other  tumors  of 
the  liver  may  cause  ascites.  Diseases  of  the  heart  or  lungs  may 
induce  ascites  in  connection  with  general  dropsy.  Bright's  dis- 
ease is  a  cause  of  hydremic  dropsy. 

Symptoms. — The  first  is  gradual  enlargement  of  the  abdo- 
men.    There    is    no    pain,   tenderness,  or    any  local    subjective 


ASCITES ASTHMA.  67 

symptoms.  The  appetite  is  usually  impaired.  There  is  a  feel- 
ing of  fullness.  There  is  dyspnoea.  The  umbilicus  is  bulged 
out.  Flatulence  and  diarrhoea  are  frequently  present.  The 
superficial  veins  on  the  abdomen  or  chest  are  enlarged  and  tor- 
tuous. The  shape  of  the  abdomen  changes  with  a  change  of  the 
position  of  the  patient.  Fluctuation  is  present.  On  percussion, 
there  will  be  flatness  below  the  level  of  the  fluid.  Ascites  may 
be  mistaken  for  an  ovarian  cyst,  a  distended  bladder,  pregnancy, 
and  hydatid  cysts  of  the  liver. 

Prognosis. — In  most  cases  unfavorable. 

Treatment. — First,  treat  the  cause  if  known.  Try  to  remove 
the  fluid  by  means  of  diuretics  and  hydragogue  cathartics;  but 
do  not  continue  the  treatment  too  long.  The  most  efficient  hy- 
dragogue is  elaterium,  and  the  potash  salts,  nitre,  squills  and 
juniper  are  the  most  efficient  diuretics.  As  little  fluid  as  possi- 
ble should  be  taken.  Tapping  is  the  surgical  method  of  remov- 
ing the  fluid.  The  puncture  is  made  in  the  median  line  two  or 
three  inches  below  the  umbilicus.  Loomis  is  in  favor  of  tapping 
before  the  fluid  has  caused  pressure  upon  the  viscera.  The  oper- 
ation of  tapping  involves  little  risk.  Patients  have  tapped 
themselves. 

For  the  general  health  give  quinine,  iron  and  cod-liver  oil. 

PRESCRIPTIONS  FOR  ASCITES. 

|fc     Elaterii gr.  j. 

Ft.  in  no  vi.  pulveres. 

Sig. :     One  powder  about  5  A.  M.  every  other  morning. 

— Salter. 

{{r     Elaterii gr.  ij. 

Ft.  in  no  viii  pulveres. 

Sig. :     One  powder  at  short  intervals  until  abundant  liquid  evac- 
uations are  produced.  — Flint. 

Jfc     Pulveris  jalapse  compositi Sj. 

Ft.  in  no  viii  pulveres. 

Sig.:     One  powder  in  early  morning.  — Bartholow. 

ASTHMA. 

Is  a  disease  characterized  by  spasmodic  difficulty  of  breath- 
ing, attended  with  wheezing  and  a  sense  of  suffocation.  It  is  a 
neuropathic  affection,    tonic    spasms  of   the   bronchial  circular 


68  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

muscular  fibres  being  induced  by  a  morbid  excitation  through 
the  nervous  system  (Flint). 

Causes. — A  peculiar  susceptibility  in  some  persons  constitutes 
the  j)redisposing  cause.  Heredity  is  traced  in  about  forty  per 
cent.  The  exciting  causes  are:  irritating  inhalations,  such  as 
ipecac  powder,  chemical  vapors,  smoke,  dust,  fog,  emanations 
from  new  mown  hay,  stables,  roses,  sulphur  matches,  cats,  horses, 
etc.  (Loomis).  Errors  in  diet,  bronchial  catarrh  and  feather 
beds  are  causes. 

Course. — -The  paroxysms  last  from  two  to  six  hours,  but 
sometimes  they  persist  for  days  (Bartholow).  They  take  place, 
usually,  during  the  sleeping  hours.  The  patient  is  unable  to  lie 
down,  but  sits  with  the  elbows  on  the  knees  near  an  open  win- 
dow. A  patient  suffering  from  a  severe  paroxysm  appears  to  be 
on  the  point  of  death.  A  frequent  symptom  is  an  itching  sensa- 
tion under  the  chin.  Sj>eech  is  difficult.  The  patient  may  be 
cyanotic  (Loomis). 

Prognosis. — Death  rarely,  if  ever  occurs  from  uncomplicated 
asthma.     Asthmatics  are  long-lived. 

Treatment. — To  relieve  the  paroxysm,  no  medication  is  so 
effective  as  the  hypodermic  injection  of  morphine  (from  T2  to 
i  gr).  Chloral  hydrate  (gr.  xx-xxx)  is  often  equally  effective 
(Bartholow).  Nitrite  of  amyl  by  inhalation,  three  to  five 
drops,  sometimes  affords  relief.  Inhalation  of  ether  or  chloro- 
form may  be  tried.  Stramonium  leaves  may  be  smoked  in  a 
pipe.     It  often  acts  like  a  charm. 

PRESCRIPTIONS  FOR  ASTHMA. 

J&     Potassii  iodidi §ss. 

Tincturse  gentianas  comp 5iij- — M. 

Sig. :     One  teaspoonful  gradually  increased  to  two  teaspoonsful, 
three  times  daily  for  several  months.  — Alonzo  Clark. 

Jfc-     Sodii  iodidi gr.  ij. 

Sodii  bromidi gr.  ij. 

Fluidi  ext.  euphorbia  pil 7X1  iij. 


Glonoin gr.' 


i 

-.>  o  <r 


Tincturse  lobelias ZTt  ij. 

(Hare's  anti-asmatic  tablet.) 

Sig. :     One  three  times  daily  for  sometime. 


ASTHMA ASTHENIA.  69 

5     Pyridin 3  j  • 

Sig. :     Put  on  a  hot  plate  in  a  small  room,  and  send  patient  to 
inhale  vapor  several  times.  — German  See. 

Jfc     Tincturre  sanguinarise 

Tincturse  lobelise 

Ammonii    iodidi — aa 5j . 

Syrupi  tolutan  5vj. — M. 

Sig.:     A    teaspoonful    every   two  to     four    hours.       (In  humid 
asthma.)  — Bartholow. 

Jfc     Ammonii  bromidi... 5iij- 

Ammonii    chioridi oiss. 

Tincturae  lobelise 5iij • 

Spiritus  setheris  compositi Sj« 

S}^rupi   acaciae — ad d 3 i v. — M. 

Sig.:     A  dessertspoonful   in   water   every    hour    or   two    during 
paroxysm .  — Pepper. 

ASTHENIA.     (Nervous). 

Literally  signifies  without  strength. 

When  the  nervous  system  is  without  strength  it  is  called 
nervous  asthenia,  or  nervous  debility,  or  nervous  prostration  or 
exhaustion,  or  simply  neurasthenia.  It  is  a  morbid  condition 
common  in  this  country. 

Causes. — Sexual  excesses,  masturbation,  excessive  mental 
labor,  late  hours,  long  continued  emotional  disturbances  of  any 
hind,  insomnia,  inrproper  food  and  the  excessive  use  of  tobacco 
or  alcohol  may  excite  it  in  persons  of  a  neurotic  ten^eranient. 

Symptoms. — Physicians  are  often  consulted  by  patients,  who, 
although  far  from  being  well,  have  no  well  defined  malady. 
They  complain  of  languor,  of  being  easily  fatigued,  and  of 
aching  of  the  limbs.  They  suffer  constantly  from  dorsal  and 
lumbar  pains,  and  there  seems  to  be  no  organ  or  part  of  the 
body  free  from  some  kind  of  disturbauce.  They  imagine  that 
they  have  some  grave  organic  disease.  There  is  a  tendency  to 
melancholia.  There  is  anorexia,  and  the  tongue  is  coated. 
Flatulence,  dyspepsia,  constipation,  headache,  palpitation  of  the 
heart,  and  tingling  and  creeping  sensations  are  usually  present. 
Chilly  sensations  alternate  with  flashes  of  heat. 

Prognosis. — Is  always  good. 


VO  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — All  causes  producing  neurasthenia  should  be 
removed.  Rest,  change  of  scene,  nutritious  diet,  out  door  life 
and  sound  sleep  tend  to  produce  a  cure.  Faradism,  galvanism, 
sea  bathing  and  massage  are  of  great  value.  Cod-liver  oil,  iron, 
strychnine,  arsenic,  phosphites  and  phosphates  are  useful. 

]J      Quinise  sulphatis gr.  xxx. 

Acidi  sulphuriei  diluti q.  s. 

Aqua? :...Sij. 

Tincturse  ferri  chloridi Sss. 

Spiritus  chloroformi 5 vj. 

Glycerinse — add oiv. — M. 

Sig.:     A  teaspoonful  three  times  daily.  — Loomis. 

APHONIA.     (Nervous). 

Is  loss  of  voice.  When  not  dependent  on  either  inflamma- 
tion or  lesions  within  the  larynx  it  is  known  as  nervous  aphonia. 

Causes. — Paralysis  of  the  nerve  of  pronation  (spinal  acces- 
sory), and  pressure  on  the  recurrent  laryngeal  nerve  by  an 
aneurism,  or  other  tumor  will  cause  aphonia. 

Diagnosis. — In  nervous  aphonia  the  patient  speaks  in  a  pure, 
soft  whisper,  without  effort.  If  the  aphonia  be  due  to  laryngitis, 
the  whisper  is  stridulous  or  husky  and  labored,  and  there  is 
usually  cough. 

Treatment. — Tonic  remedies  and  invigorating  hygienic 
measures  are  indicated.  Moderate  counter -irritation  may  be 
useful.  The  galvanic  and  faradic  currents  are  used  with  much 
success.  Sometimes  a  single  application  is  followed  by  recovery 
of  the  voice  (Flint). 

ASCARIS  LUMBRICOIDES. 

Is  the  round  worm  found  in  the  small  intestine.  It  has  a 
cylindrical  form  tapering  toward  both  ends,  like  the  common 
earth  worm.  The  total  number  of  eggs  contained  in  a  fully  de- 
veloped female  has  been  estimated  at  sixty  millions.  They  hatch 
after  being  frozen  or  dried.  The  round  worm  occasionally  enters 
the  stomach  and  is  vomited.  Sometimes  it  ascends  the  oesoph- 
agus into  the  throat,  and  enters  the  larynx  and  causes  death. 


ROUND    WORMS.  71 

It  has  been  found  in  the  common  "bile-duct,  gall -bladder, 
pancreatic- duct  and  vermiform  appendix.  These  worms,  when 
numerous,  collect  in  balls,  and  are  then  difficult  to  exjDel,  some- 
times causing  obstruction.  Length  of  worm,  six  to  twelve 
inches. 

Causes. — The  eggs  are  found  in  the  drinking  water,  in  fruits 
and  vegetables  which  are  eaten  raw,  and  thus  develop  in  the 
intestine.  Filthy  surroundings  and  uncleanliness  favor  their 
development. 

Symptoms. — The  usual  symptoms  are  colicky  pains  about  the 
umbilicus,  itching  and  picking  at  the  nose,  foul  breath,  bloody 
mucous  diarrhoea,  perverted  ajDpetite,  restlessness,  and  disturbed 
sleep  in  which  the  child  grinds  its  teeth,  sometimes  nausea  and 
vomiting,  tumid  abdomen,  whey-like  urine,  bluish  color  of 
eyelid,  and  there  may  be  convulsions.  But  the  only  symptom 
which  gives  positive  evidence  of  the  existence  of  intestinal  worms 
is  their  discovery  in  the  stools  or  about  the  anus  (Loomis). 

Treatment. — Santonine  is  the  most  effective  remedy  for  round 
worms.  Santonine  affects  the  vision  and  makes  all  objects  seem 
as  if  looked  at  through  yellow- colored  glasses  (Bartholow). 
One -half  grain  for  a  child  and  three  to  six  grains  for  an  adult  is 
a  maximum  dose  (Loomis).  The  dose  is  given  at  night,  fol- 
lowed by  a  laxative  in  the  morning. 

PRESCRIPTIONS  FOR  ROUND=WORMS. 

{&     Olei  chenopodii 5j- 

•    Acacia 3  ij- 

Syrupi  simplicis Sj • 

Aquae  cinnamomi 5 ij . — M. 

Sig. :     Give  a  dessertspoonful  three  times  a  day  for  three  days, 
and  repeat  after  several  days.  — Smith. 

Jfc     Spiritus  terebinthinae  rec 5ij. 

Olei  limonis gtt.  v. 

Mucil.  gum  acacia? 

Syrupi  sim plicis aa 5 vj . 

Aquae  anisi oii-iij • — M. 

Sig.:     One  teaspoonful  every  six  hours.  — Smith. 


72  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Jfc     Extracti  spigelise  fluidi |j 

Extracti  sermse  fluidi §ss. — M. 

Sig. :     One  teaspoonful  to  a  child  from  three  to  five  years. 

— J.  Lewis  Smith. 

ASPHYXIA. 

If  the  quantity  of  oxygen  in  the  blood  be  greatly  dimin- 
ished, there  follows  a  group  of  symptoms  to  which  the  names 
suffocation,  asphyxia  and  cyanosis  are  applied. 

Causes. — Obstruction  or  compression  of  the  air  passages,  as 
in  croup,  pneumonia,  phthisis,  pneuino- thorax,  asthma,  oedema, 
etc.;  also,  obstruction  to  the  circulation  in  the  lungs,  as  from 
embolism  of  the  pulmonary  artery  and  in  valvular  lesions  of  the 
heart ;  also  irrespirable  gases,  etc. 

Symptoms. — Dyspnoea,  convulsions,  lowering  of  the  tempera- 
ture, elevation  of  the  blood  pressure,  at  first  slow  pulse,  then 
rapid,  dilatation  of  the  pupils,  and  dark  blue  color  of  the  surface 
of  the  body. 

Treatment. — The  treatment  consists  in  removal  of  the  cause, 
if  possible,  and  in  efforts  to  increase  the  quantity  of  oxygen  in 
the  blood.  This  increase  is  best  affected  by  artificial  respiration 
(Flint). 

ATHEROMA,  OR  CHRONIC  ENDARTERITIS. 

Is  an  inflammation  of  the  internal  coat  of  the  arteries  with 
thickening  in  patches.  Calcareous  granules  infiltrate  the  coat 
and  render  the  artery  friable.     Atheroma  is  a  common  disease. 

Causes. — It  is  a  disease  of  advanced  life.  It  is  predisposed 
to  by  gout,  rheumatism,  syphilis1,  Bright's  disease,  lead  poisoning 
and  especially  by  alcoholismus  (Loomis). 

Symptoms. — Rigidity  of  the  arteries,  which  are  enlarged, 
lengthened  and  tortuous,  is  a  prominent  symptom.  The  pulse  is 
feeble.  The  left  ventricle  is  hypertrophied.  The  extremities 
are  cold.     The  skin  becomes  dry. 

Prognosis. — It  is  a  condition  which  cannot  be  cured  (Loomis). 

Treatment. — Its  treatment  is  altogether  hygienic  (Loomis). 
Bartholow  gives  arsenic  when  the  eyes  are  puffy,  breathing  short, 
and  ankles  swollen. 


BACKACHE BALANITIS— BALDNESS BED-SORES.  73 

BACKACHE. 

The  backache  so  common  in  women  and  frequently  due  to 
anaemia  of  the  cord,  may  be  much  relieved  by  a  sj)onge  dipped 
in  hot  water  and  passed  over  the  spine.  The  hot  douche  to  the 
spine  is  often  more  decidedly  serviceable  in  these  distressing 
cases  (Bartholow). 

BALANITIS. 

Is  an  inflammation  of  the  surface  of  the  glans,  penis  and 
prepuce. 

Causes. — A  long  and  tight  prepuce  is  always  a  predisposing 
cause.  The  exciting  causes  are  mechanical  irritation  or  unclean  - 
liness,  or  from  prolonged  contact  with  gonorrheal,  leucorrhceal, 
menstrual,  or  other  irritating  fluids. 

Symptoms. — Redness  and  swelling  with  ulceration  and  dis- 
charge, sometimes  followed  by  phimosis,  or  parajxhiniosis.  If 
gonorrhoea  be  the  cause,  it  is  called  external  gonorrhoea. 

Treatment. — Wash  the  parts  with  warm  water,  and  dry  them, 
and  dust  with  calomel.  If  the  ulcerations  are  deep,  use  iodo- 
form. A  piece  of  lint  or  old  linen  is  moistened  in  dilute  lead 
water,  or  a  gr.  ij.-iv.  solution  of  sulphate  of  zinc,  and  is  laid 
around  the  glans,  and  the  prepuce  is  pulled  over  it.  This  dress- 
ing should  be  repeated  two  to  four  times  daily.  If  the  prepuce 
cannot  be  retracted  it  may  be  washed  out  with  a  syringe.  If  the 
prepuce  is  much  inflamed,  rest,  position,  and  evaporating  lotions 
should  be  used.  In  cases  of  relapse  circumcision  affords  a  cure 
(Keyes). 

BALDNESS.     (See  Alopecia.) 

BASEDOW'S  DISEASE.     (See  Exophthalmic  Goitre). 

BED=SORES. 

May  be  described  as  the  death  of  a  part  from  mechanical 
pressure.  Bed-sores  may  arise  in  healthy  subjects  who  are  kept 
unmoved  for  ten  to  fourteen  days.  Dirt  and  moisture,  under  all 
circumstances,  accelerate  their  appearance. 


74  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Treatment. — "  Prevention  is  better  than  cure."  Since  bed- 
sores are  caused  by  continued  pressure,  a  change  of  the  patient's 
position  will  relieve.  The  skin  of  the  part  pressed  upon  should 
be  hardened  by  washing  it  twice  a  day  with  some  camphor  spirit 
and  water,  vinegar  and  water,  or  nitrons  ether  and  water,  in  the 
proportion  of  one  part  to  three.  It  is  a  useful  practice  to  wash 
the  parts  threatened  with  bed-sores  with  whiskey  or  alcohol;  it 
hardens  the  cuticle,  and  prevents  ulceration  (Bartholow).  Alum 
5ss.,  the  whites  of  four  eggs  and  tincture  of  camphor  5ij.,  is 
an  excellent  application  to  bed-sores  (Bartholow). 

Equal  parts  of  tincture  of  catechu  and  liquor  plumbi  is  a 
useful  application  to  prevent  bed-sores  (Ringer).  One  of  the 
best  preventives  of  bed-sores  is  glycerine,  or  glycerine  cream, 
rubbed  over  the  part  after  washing  it  with  tepid  water  (Ringer). 

The  above  applications  are  useless  when  the  parts  are  about 
to  slough.  Water  and  air  cushions  should  be  employed  to  re- 
lieve the  pressure.  Dust  iodoform  over  the  sores.  A  linseed 
and  bread  poultice,  with  charcoal  sprinkled  upon  the  surface,  is 
a  good  application  (Bryant ). 

BILIOUSNESS. 

Is  a  functional  derangement  of  the  liver. 

Causes. — It  may  be  due  to  gastric  and  intestinal  dyspej^sia, 
to  atony  of  the  bowels,  to  malaria,  to  faulty  diet,  the  food  being 
too  rich,  to  alcohol,  to  sedentary  habits,  and  ill -ventilation,  etc. 
(Loomis). 

Symptmos. — Anorexia,  a  bitter  taste  in  the  mouth,  flatu- 
lency, acidity  and  pyrosis,  a  yellowish -coated  tongue,  yellow 
conjunctiva,  muddy  skin,  nausea,  constipation,  headache,  pain  in 
the  limbs,  etc. 

Treatment. — The  bowels  should  always  be  kejyt  freely  open. 
The  alkalies  are  useful.  The  bromide  of  potassium,  combined 
with  ammonium  chloride  is  highly  useful.  Mercury,  in  the 
form  of  blue  pill,  is  very  efficacious  (Loomis). 


BILIOUSNESS BITES.  75 

PRESCRIPTIONS  FOR  BILIOUSNESS. 

J&     Acidi  nitromuriatici  diluti 3j- 

Sig. :     Ten  or  fifteen  drops,  well  diluted,  before  meals. 

— Bartholow. 
JJ-     Amrnonii  chloridi gr.  xxiij. 

Sig. :     To  be  taken  thrice  daily  in  a  glass  of  milk.    — Murchison. 

jfc     Sodii  sulphatis 

Potassi  et  sodii  tartratis aa...5j- 

Infusi  cascarilla? Sviij. — M. 

Sig. :     Two  tablespoonfuls  three  times  daily.  — Fothergill. 

Jfc     Aloni  

Extracti  nucis  vomicae aa gr.  vj. 

Extracti  belladonna? gr.  iij. — M. 

Ft.  massa  et  in  pil.  no.  xxiv.  div. 

Sig. :     One  or  two  pills  at  night,  folJowed  by  a  saline  cathartic 
before  breakfast.  — Witherstine. 

BITES. 

Tlie  weaker  solutions  of  ammonia  are  sometimes  applied  to 
the  bites  or  stings  of  insects,  as  wasps,  bees,  spiders,  etc.,  to 
neutralize  the  formic  acid,  the  active  principle  of  the  poison 
(Ringer).  Alcoholic  stimulants  are  given  to  counteract  the  de- 
pressing effects  of  the  bites  of  venomous  snakes.  The  strong 
aqua  ammonia?  should  be  at  once  applied  to  the  bite  of  venom- 
ous serpents,  and  of  rabid  animals  (Bartholow). 

Potassium  permanganate  has  been  used  with  success  as  a 
remedy  for  the  bites  of  venomous  snakes  and  other  animal  pois- 
ons, applied  locally  and  given  internally  (LaCerdo). 

PRESCRIPTIONS  FOR  BITES  (SNAKE). 

J&     Aqua?  ammonia? ZHxxx. 

Aqua? oiss. — M. 

Sig.:     To  be  injected  into  the  vein  with  hypodermic  syringe. 

—  Halford. 

Jfc     Tinctura?  iodinii 3j- 

Sig. :     Apply  freely  to  the  wound.  — Weir  Mitchell. 


76  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

BLADDER  DISEASES  (See  Cystitis). 
BLEPHARITIS 

Is  an  inflammation  of  the  eyelid.  There  are  various  degrees 
and  kinds  of  this  affection.  There  may  be  a  chronic  hyperemia 
of  the  border,  or  some  redness,  with  an  accumulation  of  yellow- 
ish fatty  material  at  the  base  of  the  lashes,  or  ulceration,  minute 
abscesses,  etc.,  and  the  hair  follicles  atrophy  and  the  lashes  fall 
out.  This  disease  occurs  most  often  in  the  young,  with  delicate 
skin  and  light  hair,  and  in  the  strumous.  It  is  sometimes  a  kind 
of  eczema.  In  very  many  cases  it  is  associated  with  some  re- 
fractive or  muscular  error,  and  the  proper  glasses  will  correct  it. 
The  ailment  is  apt  to  be  chronic  (Noyes). 

Treatment. — Soothing  lotions,  warm  water,  or  warm  milk 
and  water  are  useful;  and  at  night  a  mixture  of  boracic  acid 
powder  and  vaseline  (gr.  xxx  to  5j.)  may  be  applied  to  lids. 
For  the  ulcerative  forms,  two  grains  of  hydrarg.  oxid.  flavse  to 
one  drachm  of  vaseline,  should  be  applied  night  and  morning. 
If  the  patient  is  scrofulous,  constitutional  treatment  must  be  in- 
stituted (ISToyes). 

BLOODY  FLUX.     (See  Dysentery). 
BOILS.     (Called  also  Furuncle). 

A  boil  is  a  hard,  bounded,  deep-red,  raised  and  very  pain- 
ful swelling,  situated  in  the  subcutaneous  tissue,  occurring  on  all 
parts  of  the  body,  and  usually  terminating  in  suppuration.  Boils, 
or  furuncles,  are  met  with  in  two  forms,  one  as  a  subcutaneous 
affection,  attended  with  little  pain  until  the  skin  over  it  inflames 
and  suppurates.  It  then  appears  as  a  conical-pointed  swelling, 
with  inflamed  indurated  areola;  this  causes  severe  distress,  tension 
and  throbbing,  and  is  followed  by  relief  when  the  "core"  is 
discharged. 

The  second  form  of  boil  begins  as  an  inflamed  follicle  or 
pimple.  It  suppurates  slowly.  Such  boils  are  usually  multiple, 
and  are  often  caused  by  the  application  of  moist  dressings  or  of 
some  cadaveric  irritant  (Bryant). 


BOILS BLOOD    POISONING BREATH.  77 

Causes. — No  definite  cause  can  be  assigned  in  some  cases. 
Boils  occur  in  men  and  women  who  are  in  perfect  health;  hut 
they  are  more  common  in  debilitated  persons,  and  in  those  who 
work  in  skin -yards,  pathological  rooms  and  dissecting  rooms. 
They  occur  in  the  diabetic  and  cachectic  subject,  and  are  often 
the  result  of  eating  diseased  meat  (Bryant). 

Treatment. — Is  both  local  and  constitutional.  The  diet 
should  be  nutritious;  fresh  air,  exercise,  mild  laxatives,  warm 
baths,  Ojuinine,  iron,  arsenic  and  'bitters  are  useful.  The  usual 
local  treatment  is  a  poultice  to  the  part  and  free  incision.  For  in- 
dolent boils,  a  drachm  each  of  glycerine  and  extract  of  opium, 
and  an  ounce  of  resin  cerate  applied  relieves  the  pain.  Painting 
the  boil  with  iodine  is  recommended.  When  the  pain  is  great 
from  tension,  lancing  relieves  it. 

PRESCRIPTIONS  FOR  BOILS. 

|Jr     Liquoris  potassii  arsenitis 5vj. 

Sig. :     Three  drops  in  water,  three  times  daily  after  meals. 

Jfc     Calcii  sulphidi gr.  ij. 

Sacchari  lactis gr.  xx. — M. 

Ft.  in  no.  xx.  pulveres. 

Sig. :     One  powder  every  hour  or  two.  — Ringer. 

Faradization  will  hasten  suppuration  (Rockwell). 
BLOOD  POISONING.     (See  Septicemia). 
BREATH  (Foul). 

To  correct  fetor  of  the  breath,  the  following  formulae  may 
be  used: 

Jfc     Calcis  chloratse   5iij- 

Aquas  destillatse Si] - 

Alcoholis Sij . 

Olei  rosae gtt.  iv. — M. 

Sig. :     A  teaspoonful  to  a  tumblerful  of  water.  — Bartholow. 

|fc     Potassii  permanganatis   gr.  viij. 

Aqua?  rosse 3  viij. — M. 

Sig. :  Use  as  a  mouth  wash.  This  is  an  elegant  toilet  prepara- 
tion for  destroying  the  odor  of  a  foul  breath,  the  smell  of  the  axilla, 
and  the  fetor  of  the  sweat  of  the  feet.  — Bartholow. 


78  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

BREAST.     (Inflammation  of). 

The  subcutaneous  inflammation  may  be  confined  to  the 
areola,  and  this  form  generally  terminates  in  suppuration.  In 
other  cases  the  inflammation  may  extend  beyond  the  areola  and 
give  rise  to  localized  abscesses. 

The  treatment  in  both  of  these  forms  consists  in  the  appli- 
cation of  warm  lead-lotions  and  in  the  early  evacuation  of  the 
pus.  To  avoid  cutting  into  the  milk  ducts  the  incision  should 
radiate  from  the  nipple  (Lusk).  Inflammation  of  the  glandular 
structure  of  the  breast  develops  usually  in  the  first  four  weeks 
after  confinement.  The  attack  usually  begins  with  a  sharp  chill, 
pain,  high  fever,  and  nodular  enlargement  of  the  breast.  The 
mastitis  that  occurs  three  to  four  days  after  the  birth  of  the 
child  is,  as  a  rule,  insignificant,  but  the  mastitis  leading  to 
abscess  formation  belongs  to  a  later  period,  third  or  fourth  week. 

Causes. — Are  cold,  blows,  and  "caking,71  but  the  lesions  of 
the  nipples  are  thought  to  be  the  main  cause. 

Treatment. — Take  the  child  from  the  breast,  and  in  a  very 
large  number  of  cases  the  inflammation  will  disappear.  For  the 
pain,  opium ;  for  the  fever,  a  full  dose  of  quinine  should  be 
administered.  Give  a  saline  cathartic.  Belladonna  in  the  form 
of  an  ointment  may  be  applied  to  the  breast,  or  lead- and- opium 
wash,  or  a  large  flax-seed  poultice.  As  soon  as  there  is  evidence 
of  pus,  the  abscess  should  be  opened  with  antiseptic  precautions 
(Lusk). 

BRONCHOCELE.  (See  Goitre). 

BUBONOCELE.  (See  Hernia). 

When  the  protrusion  takes  place  above  Poupart's  ligament, 
through  the  internal  ring,  but  does  not  traverse  the  inguinal 
canal  sufficiently  far  to  appear  through  the  external  ring,  the 
hernia  is  called  a  bubonocele  (Bryant). 

BORBORYGMUS. 

Is  a  rumbling  noise  of  intestinal  flatus,  or  wind,  due  to  indi- 
gestion and  decomposition  of  food.  The  noise  can  often  be  heard 
at  a  distance  of  ten  feet  or  more  when  the  person  is  walking. 


B0RB0RYGMUS BRONCHITIS.  79 

Treatment. — Give  stomachic  and  intestinal  tonics,  such  as 
quinine  in  half  grain  closes  three  times  daily,  gentian,  quassia, 
Colombo,  and  wild  cherry.  Liquids  should  he  withheld  and  all 
articles  difficult  of  digestion. 

BRONCHITIS. 

Is  a  catarrhal  inflammation  of  the  bronchial  mucous  mem- 
brane. 

Varieties. — 1.  Acute  bronchitis,  of  the  large  tubes.  2.  Acute 
capillary  bronchitis.     3.  Chronic  bronchitis. 

Morbid  Anatomy. — There  is  first  hyperaemia  or  congestion  of 
the  mucous  membrane,  which  becomes  swollen  and  soft.  Then 
follows  the  products  of  inflammation,  such  as  mucus,  pus- 
corpuscles,  and  serum  mixed  with  desquamated  epithelial  cells. 
Generally  the  tubes  on  both  sides  are  equally  affected,  and  thus 
bronchitis  exemplifies  the  law  of  parallelism,  and  is  called  a 
bilateral  disease.  In  this  respect  it  differs  from  pleurisy  and 
pneumonia  (Flint). 

Causes. — Exposure  to  cold  damp  winds,  unsuitable  clothing, 
depression  of  vitality,  bad  hygiene,  and  irritating  gases  are 
common  causes.  The  predisposing  causes  are  infancy  and  old 
age. 

Symptoms. — Its  invasion  is  commonly  marked  by  coryza, 
lachrymation,  sore  throat  and  slight  hoarseness,  with  chilliness. 
The  pulse  is  increased  in  frequency,  and  there  is  aching  in  the 
back  and  limbs.  More  or  less  pain  and  discomfort  are  felt  be- 
hind the  sternum.  The  cough  is  at  first  dry  and  hacking,  but 
in  a  few  days  becomes  loose,  and  is  attended  with  a  frothy  muco- 
purulent expectoration.  Acute  bronchitis  lasts  from  four  or  five 
days  to  two  or  three  weeks. 

Differential  Diagnosis. — Acute  bronchitis  may  be  confounded 
with  pneumonia  and  pleurisy.  The  absence  of  lancinating  pains 
in  either  side,  the  pain  which  is  felt  being  substernal  ;  the  pres- 
ence of  more  or  less  expectoration  which  is  not  rusty;  the  absence 
of  accelerated  breathing  and  dyspnoea;  absence  of  the  circum- 
scribed flush  of  the  cheek;  the  pre-existence  of  coryza,  are  usu- 


80  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ally  sufficient  to  distinguish  it  from  pneumonia  and  pleurisy. 
Besides  bronchitis  commences  by  chilliness  persisting  for  several 
days — pneumonia  by  a  distant  and  severe  rigor.  In  bronchitis, 
the  fever  declines  gradually,  in  pneumonia,  there  is  a  sudden 
defervescence. 

Treatment. — The  combination  of  tartar  emetic  (gr.  tV)  and 
morphine  (gr.  TV)  in  some  syrup  of  lactucarium,  or  in  water, 
a  mustard-plaster  to  the  chest,  and  confinement  to  bed,  will 
afford  relief  (Bartholow).  In  children,  syrup  of  ipecac,  syrup 
of  tolu,  and  paregoric,  usually  suffice.  If  there  is  much  fever 
and  the  pulse  active,  tincture  of  aconite  root  (gtt.  j.)  should  be 
added  (Bartholow).  At  the  onset  of  the  disease,  it  may  be 
arrested  by  a  Dover's  powder  (gr.  x.)  and  warm  bath  at  night, 
followed  in  the  morning  by  a  brisk  saline  purge ;  or  gr.  xx.  of 
quinine  (Loomis). 

PRESCRIPTIONS  FOR  BRONCHITIS. 

Jfc     Tinctures  sanguinarias 3j. 

Tincturas  lobelias 31 . 

Vini  ipecac 31J . 

Syrupi  tolutan §ss. — M. 

Sig.:     A  teaspoonful  every  three  hours.  — Eartholow. 

{fc     Ammonii  carbonatis gr.  xL. 

Spiriti  chloroformi ^ss. 

Infusi  senegas ^viij. — M. 

Sig.:     Two  tablespoonfuls  every  four  or  six  hours.    — Fothergill. 

JJr     Acidi  hydrocyanici  diluti ITT  xvi. 

Syrupi  pruni  Virginianas 

Aquas  camphoras aa §j . — M. 

Sig.:     A  teaspoonful  every  two  or  three  hours.         — Hartshorne. 

{£     Vini  ipecac  3J . 

Tincturas  scilke 31J. 

Syrupi  tolutan 3iv. 

Aquas 31. — M. 

Sig.:     A  teaspoonful  every  three  or  four  hours.  — Delafield. 

JJr     Terpine  hydrate Sss. 

Sig.:     Two  to  four  drops  on  sugar  every   four  hours  according  to 
child's  age.  — Cammann. 


BRONCHITIS.  81 

JJr     Vini  ipecac gij. 

Liquor  potassii  citratis 3iv. 

Tincturse  opii  camphoratse 

Syrupi  acacias  aa. oj- — M 

Sig. :     A  tablespoonful  three  times  daily.  — DaCosta. 

{fc     Vini  ipecac oij- 

Vini  antimonialis gj . 

Vini  xerici  oiij- — M. 

Sig.:     Three  drops  every  hour  to  a  child  six  months  old. 

—Dessau. 

BRONCHITIS.      (Acute  Capillary). 

Acute  bronchitis,  by  an  extension  of  the  inflammation  to  the 
finest  tubes,  becomes  capillary  bronchitis.  Capillary  bronchitis 
is  more  frequent  in  infancy  and  old  age  than  at  other  periods 
of  life  (Bartholow). 

Symptoms. — So  difficult  is  the  breathing  that  the  patient  is 
unable  to  lie  down,  he  sits  inclined  forward,  and  the  respirations 
are  shallow,  reaching  in  the  adult  to  forty,  in  infants  to  eighty 
per  minute.  The  difficulty  of  breathing  is  incessant.  The  in- 
ferior part  of  the  chest  and  the  epigastrium  are  drawn  in  with 
each  inspiration  instead  of  being  elevated,  while  the  upper  por- 
tion of  the  chest  remains  immovable  (Bartholow).  The  speech 
is  short  and  jerky;  the  alse  nasi  dilate,  the  face  is  congested  and 
swollen,  has  a  livid  aspect,  the  lips  become  blue,  and  there  is 
blueness  of  the  finger  ends,  with  fullness  of  the  jugular  veins 
(Loomis).  Cough  is  more  or  less  prominent.  The  expectoration 
is,  at  first,  thick,  viscid  and  tough,  and  when  some  is  put  in 
water  the  froth  floats  and  is  connected  by  filaments  with  the 
heavier  masses  underneath  the  surface.  There  is  great  restless- 
ness and  anxiety.  As  death  approaches,  the  pulse  becomes  small 
and  thready,  muttering  delirium  comes  on,  or  the  patient  lies  in 
a  state  of  partial  coma  (Loomis). 

Physical  Signs. — The  presence  of  muco- purulent  liquid  in 
the  small  tubes  gives  rise  to  fine  bubbling  (subcrepitant)  rales. 
As  the  affection  is  bilateral,  the  rales  are  heard  on  both  sides. 

Differential  Diagnosis. — Capillary  bronchitis  may  be  con- 
founded with  pneumonia,  asthma,  pulmonary  oedema,  phthisis 


82  A    COMPENDIUM    OF    PRACTICAL     MEDICINE'. 

and  ordinary  bronchitis;  Lobar  pneumonia  is  to  be  excluded 
by  the  absence  of  the  symptoms  and  signs  of  that  disease,  such 
as  dullness  on  percussion,  the  crepitant  rale,  pain  in  the  side,  the 
rusty  colored  sputum,  etc.  Asthma  is  not  accompanied  by 
pyrexia.     In  asthma  the  respirations   are  not  rapid  but  labored. 

Prognosis — Unfavorable. 

Treatment. — Breathing  warm  vapor  is  highly  useful,  and 
the  air  of  the  room  should  be  charged  with  steam  during  the 
course  of  the  disease.  The  temperature  of  the  room  should  be 
kept  at  a  high  point,  85°  to  90°.  The  iodide  of  potassium  should 
be  given  freely  (Flint).  Muriate  of  ammonia,  or  chlorate  of 
potash  in  five  or  ten  grain  doses  every  two  hours  to  an  adult  is 
useful  (Loomis).  Laxatives  are  useful  and  revulsive  applica- 
tions to  the  chest.  Emetics  are  sometimes  indicated  to  promote 
the  expectoration.  In  the  advanced  stage,  quinine  and  stimu- 
lants must  be  given. 

PRESCRIPTIONS  FOR  CAPILLARY  BRONCHITIS. 

|fc     Liquoris  ammonii  acetatis Sss. 

Sy rupi  ipecac 5j  • 

Liquoris  morphinas  sulphatis IHxL. 

Syrupi  acacias 5j. 

Aquse o  iss.  — M. 

Sig. ;     A  teaspoonful  every  two  hours  for  a  child  two  years  old. 

— Meigs  and  Pepper. 

|&     Tincturas  aconiti  radicis  Sss. 

Sig.:     One  or  two  drops  every  hour.  — Dessau. 

BRONCHITIS.     (Chronic). 

Is  a  chronic  inflammation  of  the  mucous  membranes  of  the 
bronchial  tubes.  "When  the  secretion  is  retained  and  undergoes 
decomposition,  as  is  apt  to  be  the  case  when  the  tubes  are  di- 
lated, it  is  known  as  fetid  bronchitis. 

The  diagnosis  is  easily  made. 

Treatment. — Iron,  quinine,  arsenic,  lacto- phosphate  of  lime, 
hypophosphites,  cod-liver  oil,  whiskey  and  strychnine,  and  a 
generous  diet  are  indicated. 

For  fetid  bronchitis,  the  spray  of  a  solution  of  carbolic  acid 
is  good. 


beight's  disease.  83 

BRIGHT'S  DISEASE. 

Acute  Briglit's  disease,  or  acute  diffuse  nephritis,  is  a  dis- 
ease of  the  kidneys  characterized  by  albuminuria  and  general 
dropsy.  It  is  an  inflammation  of  the  kidneys.  Anasarca  and 
serous  accumulations  in  the  plural,  pericardial  and  j)eritoneal 
cavities  are  usually  met  with  in  the  bodies  of  those  dead  of  acute 
Bright1  s  disease  (Flint). 

Causation. — Acute  Bright's  disease  may  occur  at  any  period 
of  life.  In  the  majority  of  cases  it  is  a  sequel  of  scarlatina.  It 
may  follow  diphtheria  and  epidemic  cholera.  It  may  occur  in  the 
course  of  pulmonary  tuberculosis,  rheumatism,  syphilis,  typhoid 
and  typhus  fever,  yellow  fever,  erysipelas,  acute  lobar  pneu- 
monia, pyaemia,  septicaemia,  endocarditis,  dysentery,  carbuncles, 
small-pox  and  measles.  As  a  primary  affection  it  occurs 
especially  in  persons  addicted  to  intemperance.  It  may  be 
caused  by  exposure  to  cold,  and  by  extensive  burns.  Other 
causes  are,  cantharides,  turpentine,  phosphorus,  carbolic  acid, 
iodoform,  the  mineral  acids,  arsenic,  lead  and  mercury  taken  in- 
ternally (Bartholow,  Flint,  and  Loomis). 

Symptoms. — Dropsy  is  an  early  symptom  in  the  great  major- 
ity of  cases,  but  it  is  sometimes  wanting.  The  oedema  is  gener- 
ally first  observed  on  the  face,  particularly  on  the  eyelids  and 
around  the  eyes.  There  may  be  fever,  thirst,  anorexia,  rjain  and 
tenderness  in  the  loins.  Pain  over  the  kidneys  may  be  wanting. 
The  quantity  of  urine  is  usually  diminished,  and  it  may  be  very 
scanty.  The  urine  contains  albumen  frequently  in  great  abund- 
ance. In  some  cases  the  urine  has  a  reddish -brown,  smoky  ap- 
pearance from  the  presence  of  blood.  Blood  casts,  epithelial 
casts,  and  hyaline  casts  are  usually  present  in  the  urine.  Urea 
may  collect  in  the  blood  and  cause  uraemia.  Impaired  vision 
and  amaurosis  are  among  the  effects  of  uraemia.  Blindness  in 
acute  albuminuria  is  generally  sudden;  but  is  often  temporary. 
The  ophthalmoscope  shows  no  morbid  appearances  within  the 
eye.  The  morbid  condition  is  central.  The  average  duration  of 
the  disease  is  about  four  weeks  (Flint). 

Prognosis. — Exclusive  of  uraemia  and  serious  complications 
the  prognosis  is  favorable  (Flint). 


84  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — The  patient  should  be  kejri  warm  in  bed.  The 
diet  should  be  unstiniulating.  Dry  cupping  over  the  loins,  saline 
laxatives,  and  fomentations  over  the  region  of  the  kidneys  are 
useful.  For  the  dropsy  elaterium  is  the  most  prompt  and  relia- 
ble hydragogue.  The  diuretics  to  be  used  are  bitartrate  of 
potassa,  the  infusion  of  digitalis,  and  the  decoction  of  broom. 

Of  all  diuretics,  water  is  the  best. 

Good  sudorific  remedies  are  pilocarpine  and  the  liquor  am- 
nionise  acetatis  (Flint). 

PRESCRIPTIONS  FOR  BRIGHT'S  DISEASE. 

|&     Acidi  gallici 5i-ij 

Acidi  sulphurici  dil  5ss. 

Tincturee  lupuli 3] 

Infusi  lupuli ad 5 vi. — M. 

Sig. :     A  tablespoonful  thrice  daily.     (If  urine  is  smoky). 

— Aitken- 

{£•     Ferri  sulphatis gr.  xv. 

Magnesii  sulphatis Sjj. 

Potassii  bicarbonatis 5iij- 

Infusi  buchu 5 viij . — M. 

Sig. :     A  tablespoonful  once  or  twice  a  day  in  a  tumblerful  of 
water.  — Fothergill. 

|lr     Infusi  digitalis Sviij. 

Sig. :     A  tablespoonful  morning  and  evening. 

(For  the  dropsy  of  Bright's  Disease.  — Bartholow. 

Albuminuria,  dropsy,  and  uraemia  are  common  to  both  acute 
and  chronic  Bright^s  Disease  (Flint). 

BUBO. 

Is  a  circumscribed  swelling  and  inflammation  of  the  groin,, 
or  of  a  lymphatic  gland,  syphilitic  or  otherwise. 

Varieties. — 1.  Simple  inflammatory  bubo.  2.  Virulent  bubo. 
3.  Syphilitic  bubo. 

Causes. — Simple  inflammatory  bubo  is  very  common  with 
chancroid,  and  may  occur  with  any  inflammatory  lesion,  as  gonor- 
rhoea, syphilitic  chancre,  herpes,  and  balanitis.  This  form  is 
also  known  as  sympathetic  bubo.     It  is  the  same  inflammatory 


BUBO.  85 

glandular  swelling  as  occurs  after  vaccination,  or  from  an  in- 
flamed corn.  Any  inflammatory  lesion  of  the  penis  may  be  ac- 
companied by  a  simple  bubo,  (single  or  double)  in  the  groin. 
Chancroid  is  the  most  common  exciting  cause  (Keyes). 

Virulent  bubo,  the  pus  of  which  is  auto-inoculable,  can  be 
found  in  connection  with  no  other  conceivable  lesion  than  chan- 
croid. It  is  usually  single,  in  one  gland,  on  one  side.  It  sup- 
purates necessarily.  Simple  bubo  usually  does,  but  may  not 
suppurate.     Pure  syphilitic  bubo  does  not  supjjurate. 

Bubo  is  more  common  in  the  male  than  in  the  female. 
Sometimes  in  double  bubo,  simple  bubo  will  exist  on  one  side 
and  virulent  on  the  other  (Keyes). 

Diagnosis. — Syphilitic  Bubo:  1.  Nature:  It  is  a  specific 
affection.  2.  Its  frequency:  It  is  a  constant  symptom  attending 
syphilitic  chancre.  3.  Number  of  glands  involved:  Usually 
more  than  one.  4.  Date  of  appearance:  It  develops  during  the 
first  or  second  week  of  syphilitic  chancre.  5.  Size:  The  glands 
are  usually  only  slightly  enlarged.  6.  Induration:  The  glands 
are  specifically  indurated,  feeling  like  cartilage,  or  wood.  7. 
Evidence  of  inflammation:  None;  the  glands  are  freely  movable 
among  the  tissues.  The  skin  is  neither  adherent  nor  red,  nor  is 
there  any  pain.  8.  Termination  always  in  resolution.  9.  Auto- 
inoculability:  In  cases  of  suppuration  the  pus  is  not  auto-inoc- 
ulable. 10.  Natural  duration  is  a  few  weeks  or  months.  11. 
Prognosis  is  good  as  far  as  local  results  are  concerned,  but  the 
patient  invariably  has  syphilis.  12.  Local  treatment  is  inef- 
fective (Keyes). 

.Bubo  of  Chancroid:  1.  Nature:  It  may  be  simple  or  viru- 
lent. 2.  Its  frequency:  It  is  a  complication,  occurring  about 
once  in  three  cases.  3.  Number  of  glands  involved:  Usually 
consists  of  a  single  gland  in  any  part  of  the  body.  4.  Date  of 
appearance:  There  is  no  fixed  date.  5.  Size:  The  gland  is 
greatly  enlarged.  6.  Induration:  No  hardness  except  inflamma- 
tory. 7.  Evidence  of  inflammation:  There  is  every  appearance 
of  inflammation.  The  gland  becomes  fixed,  the  skin  adherent, 
the  part  feels  hot,  there  is  pain,  the  skin  reddens.  8.  Termina- 
tion: Occasionally  by  resolution,  usually  by  suppuration.  I  riru- 
lent  bubo  invariably  suppurates  and  becomes  an  open  chancroid 


86  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ulcer.  9.  Auto-inoculability:  When  the  bubo  is  inilaniniatoiy 
the  pus  is  not  auto-inoculable;  where  it  is  virulent  the  pus  is 
invariably  auto-inoculable.  10.  Natural  duration  is  a  few  weeks 
or  many  months  as  a  chancroid.  11.  Prognosis  is  good  for  sim- 
ple, less  so  for  virulent,  and,  in  neither  case,  does  syphilis  follow. 
12.  Local  treatment  useful  and  necessary  (Keyes). 

Treatment. — The  preventive  treatment  of  simple  bubo  is 
rest,  and  absolute  destruction  of  the  chancroid  with  caustics. 
Tincture  of  aconite  and  belladonna,  combined  in  equal  parts,  are 
of  some  use  locally,  especially  if  combined  with  rest.  Tincture 
of  iodine  is  useless,  if  not  harmful,  in  acute  advancing  bubo. 
The  above  treatment,  combined  with  a  light  poultice,  will  often 
avert  impending  bubo  (simple).  Blisters  may  avert  suppuration. 
Pressure  is  sometimes  effective,  if  applied  early.  If  the  tendency 
to  suppuration  advances  very  slowly,  the  bubo  is  certainly 
simple;  if  rapidly,  virulent.  When  opened  spontaneously  or  by 
art,  the  outlet  does  not  enlarge  in  simple  bubo;  in  virulent  bubo 
it  does.  If  suppuration  can  be  arrested  in  an  inflamed  gland,  it 
must  have  been  simple  bubo,  (unless  syphilitic) ;  virulent  bubo 
must  necessarily  suppurate.  It  is  a  good  rule  to  open  the  bubo 
early  in  any  case,  if  pus  be  jxresent.  The  treatment  of  syphilitic 
bubo  is  that  of  early  syphilis  (Keyes). 

PRESCRIPTIONS  FOR  BUBO. 

Jfc     Cerati  resinse  comp .....5j. 

Olei  Olivte 5i-ij  —  M. 

Sig.:     Spread  on  lint  and  apply.     (To  hasten  suppuration  and 
granulation).  — Witherstine. 

J£     Sol.  hydrogen  peroxidi...lO  vol...§viij. 
Sig.:     Apply  after  suppuration  has  begun.  — Ringer. 

Jfc     Tincturse  iodi oj 

Sig. :     Apply  with  brush  every  other  day,  till  skin  becomes  tender. 

— Van  Buren. 

BUNION. 

Is  an  enlargement  and  inflammation  of  the  bursa  situated 
upon  the  side  of  the  great  toe  at  the  metatarso- phalangeal  junc- 
tion.    Inflammation   of  this  bursa  is  frequently  so  severe  that 


BUNIONS BURNS    AND    SCALDS.  87 

the  reflex  contractions  which  follow  produce  a  sub- luxation  at 
this  joint.  The  bursa  may  suppurate.  The  pain  is  sometimes 
intense  and  torturing  (Sayre). 

Causes. — Ill-fitting  boots  and  shoes,  and  weight  from  over- 
standing. 

Treatment. — Under  all  circumstances,  the  pressure  must  be 
removed.  A  wide  and  easy  boot  should  be  worn.  To  the  in- 
flamed bunion  water  dressing  is  the  best  application.  By  means 
of  Sayre's  apparatus  keep  the  great  toe  in  a  straight  line  with 
the  foot. 

PRESCRIPTIONS  FOR  BUNIONS. 

/ 

{&     Acidi  tannici  , 

Cosmolini aa 5ij- — M. 

Sig. :     Apply  to  joint  after  skin  has  been  removed  by  blister. 

— Gross. 

Jfc     Tincturse  iodi 

Tincturse  belladonna aa 5ij- — M. 

Sig.:     Apply  twice  daily  with  a  brush.  — A.  U.  Med.  Sci. 

BURNS  AND  SCALDS. 

A  burn  is  casued  by  the  application  of  concentrated  dry 
heat  to  the  body;  a  scald  by  the  application  of  hot  or  boiling 
liquid.  In  a  burn  of  the  first  degree,  there  is  mere  redness  fol- 
lowed by  desquamation.  In  the  second  degree,  there  is  inflam- 
mation and  a  blister.  In  the  third  degree,  the  superficial  layer 
of  the  true  skin  is  destroyed,  and  when  shed,  the  nerves  are  ex- 
posed and  pain  severe.  In  the  fourth  degree,  the  whole  thick- 
ness of  skin  is  destroyed,  and  when  the  dry  eschar  comes  away, 
a  tedious  process  of  suppuration  and  granulation  takes  place. 
In  the  fifth  degree,  the  skin  with  the  deeper  parts  is  a  black 
mass.  In  the  sixth  degree,  the  whole  thickness  of  the  limb  is 
carbonized  (Bryant). 

Prognosis. — A  superficial  burn  spread  over  a  large  surface  is 
more  fatal  than  a  deep  burn  on  a  small  surface.  When  more 
than  half  of  the  body  is  injured  by  a  burn  or  sea  Id,  a  fatal  result 
generally  follows.     In    both    old    and    young   all   burns  of  any 


88  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

extent  are  serious.  Burns  of  the  chest,  abdomen,  head  and  face 
are  followed  by  much  more  severe  symptoms  than  more  exten- 
sive burns  of  the  extremities  (Bryant). 

Symptoms. — The  earliest  symptoms  are  those  of  shock.  The 
skin  is  cold,  accompanied  by  shivering.  The  pulse  is  rapid  and 
feeble.  The  pain  is  severe  and  of  greater  intensity  in  slight  than 
in  deep  burns.  In  the  worst  cases,  pain  is  nearly  or  quite  absent. 
In  children  vomiting  is  an  early  symptom.  The  patient  may 
lapse  into  a  drowsy  condition  followed  by  coma  and  death.  If 
life  be  prolonged,  reaction  sets  in  after  twenty-four  to  forty- eight 
hours,  and  traumatic  fever.  In  severe  burns  we  may  have  ulcer- 
ation of  the  duodenum  (Bryant). 

Casting  Off  of  Sloughs. — The  slough  separates  in  about  four- 
teen days,  and  then  suppuration  commences.  In  the  suppuration 
stage,  there  is  great  danger  of  exhaustion,  hectic  or  pyaemia. 
The  granulating  surface  is  a  long  time  in  healing,  and  is  followed 
by  contraction  if  the  whole  skin  has  been  destroyed. 

Cause  of  Death. — When  a  person  dies  from  a  burn  within 
forty- eight  hours,  it  arises  from  shock,  or  collapse;  when  he  dies 
in  the  stage  of  reaction  or  of  inflammation,  it  is  from  visceral 
complication ;  and  Avhen  during  the  third  or  suppurative  stage, 
from  exhaustion,  visceral  changes  or  pyaemia  (Bryant). 

Treatment. — Is  both  constitutional  and  local.  Prevent  col- 
lapse by  use  of  stimulants  and  external  warmth  ;  allay  pain  by 
local  treatment  and  morphine ;  maintain  the  strength  by  such 
food  as  milk,  beef-tea,  eggs,  etc. 

Local  Treatment. — Blisters  should  be  opened  carefully. 
Exclude  the  air  as  much  as  possible.  At  Guy's  hospital  the 
application  of  carron  oil,  consisting  of  equal  parts  of  lime  water 
and  linseed  oil,  applied  on  lint,  has  long  been  the  favorite 
remedy.  At  University  College  the  burn  is  covered  with  wheat 
ilour.  Zinc  ointment  on  lint  is  used  at  London  Hosrjital.  Dr. 
Gross  used  white  lead  paint.  Bryant  uses  vaseline  and  finely 
powdered  boracic  acid  spread  on  lint.  In  small  burns,  two  parts 
of  collodion  to  one  of  castor  oil  is  used,  or  one  ounce  of  carbolic 
acid  to  a  rnnt  of  olive  oil,  or  an  ointment  of  carbolic  acid  5iv., 
lard  5iv.,  and  castor  oil  ryj.  Extension  must  be  kept  up  to 
prevent  contraction.     Skin-grafting  may  be  necessary. 


BURNS    AND    SCALDS CALCULI.  89 

PRESCRIPTIONS  FOR  BURNS  AND  SCALDS. 

jfc     Acidi  carbolici gr.  viij. 

Vaseline §ij . — M. 

Sig. :     Spread  on  lint  and  apply  where  the  skin  is  broken. 

— Bellevue  Hospital. 

{fcr     Sodii  bicarbonatis §ij. 

Aqua? Oj . — M. 

Sig.:     Apply  freely  on  lint  or  soft  cotton. 

JJr     Oleilini 

Liquoris  calcis aa . .  .^i v. 

Acidi  carbolici gtt.  xxx  — M. 

Sig. :     Apply  freely.  — Charity  Hospital. 

Jfc     Cocaini gr.  x-xx. 

Boroglyceridi §ij. — M. 

Sig. :     Apply  locally  on  absorbent  cotton.  — Eller. 

]£      Saloli  5ss. 

Liquoris  calcis 

Olei  olivas aa |..ij. — M. 

Sig. :     Use  locally.  — Nicot. 

CALCULI.     (Biliary,  Renal,  and  Vesical.) 

When  bile  is  retained  in  the  gall-bladder  for  a  long  time  it 
decomposes,  and  the  cholate  of  soda  and  other  bile  salts,  with 
cholesterine,  globules  of  bile -resin  and  granules  are  precipitated, 
and  combine  to  form  concretions,  which  are  called  biliary  cal- 
culi, or  gall-stones.  Catarrh  of  the  gall-bladder  always  accom- 
panies this  retention  and  decomposition  of  bile  (Loomis). 

Number  of  GalI=Stones. — Varies.  Single  calculi  are  rare. 
Eight  thousand  were  found  in  one  case.  Their  usual  number  is 
about  thirty.  Their  size  varies  from  that  of  a  pin's  head  to  that 
of  a  goose  egg.  In  shape  they  are  originally  spherical,  ovoid,  or 
pear-shaped,  but  when  they  lie  in  contact  with  one  another  they 
may  have  facets. 

Color. — They  may  be  light  brown,  or  greenish  yellow,  or 
white,  green,  blue,  red  or  black.  Gall-stones  will  not  float  in 
water.  In  most  cases  a  fresh  biliary  calculus  can  be  crushed 
between  the   fingers.     A  gall-stone   may  form    in    the  smallest 


90  A    C03IPEXDILTM    OF    PRACTICAL     MEDICIXE. 

radical  of  the  hepatic  duct.  The  gall-bladder  may  be  normal  or 
enlarged,  and  is  often  adherent  to  adjacent  organs.  Ulceration 
of  the  walls  may  take  place  and  form  openings,  called  biliary 
fistula.  When  calculi  are  found  in  the  smaller  ducts,  they  may 
excite  abscess  of  the  liver.  Gall-stones  may  cause  intestinal 
obstruction  (Loomis). 

Causes. — Gall-stones  may  be  formed  at  any  period  of  life, 
but  are  most  frequent  after  thirty-five.  They  are  more  common 
in  women  than  in  men  on  account  of  their  less  active  mode  of 
life.  Those  who  have  to  pass  the  greater  part  of  their  lives  in 
bed,  and  prisoners,  are  especially  liable  to  gall-stones.  The 
predisposing  causes  are,  a  diet  rich  in  fats,  animal  food,  alcoholic 
beverages,  cancer  of  the  liver,  catarrh  of  the  gall-bladder,  etc. 
(Loomis). 

Symptoms.-The  severely  painful  sensation  produced  by  the 
passage  of  a  gall-stone  is  called  biliary  colic.  Usually  after  a 
hearty  meal,  or  after  some  jolting  exercise,  as  horseback  riding, 
the  patient  is  suddenly  seized  with  a  severe  pain  in  the  epigas- 
trium,  which  is  increased  by  change  of  position  or  pressure. 
Sometimes  nausea  precedes  the  colic.  The  pain  is  paroxysmal, 
situated  over  the  gall-bladder,  radiates  backward  and  upward, 
and  may  extend  over  both  hypochondriac  regions.  It  is  a  boring, 
tearing,  piercing,  or  lancinating  pain.  It  is  often  so  agonizing 
that  patients  will  roll  about  the  floor  or  bed.  The  face  is  pale 
and  covered  with  cold  sweat.  The  abdominal  muscles  are  rigid 
and  pressure  greatly  augments  the  pain.  Fatal  syncope  has 
occurred  during  an  attack  of  gall-stone  colic.  After  a  few  hours, 
sometime&  a  day,  of  exhausting  and  intense  pain,  the  patient 
experiences  sudden  relief,  and  the  pain  entirely  disappears. 
Jaundice  is  often  present,  but  not  until  the  attack  has  continued 
for  twenty-four  hours.  After  the  attack,  gall-stones  may  be 
found  in  the  faeces  (Loomis). 

Differential  Diagnosis. — Gall-stone  colic  may  be  mistaken 
for  cardialgia,  intestinal,  and  renal  colic.  In  cardialgia,  pain 
comes  on  immediately  after  eating;  gall-stone  colic  has  no  neces- 
sary connection  with  taking  food.  In  cardialgia,  the  symptoms 
are  referred  to  the  epigastrium  alone,  while  in  biliary  colic,  the 
pain  shoots  to  the  right  shoulder  and  back.     In  cardialgia,  the 


CALCULI.  91 

pain  gradually  diminishes;  in  biliary  colic  it  suddenly  ceases. 
In  gall-stone  colic,  the  presence  of  a  gall-stone  in  the  faeces  is 
pathognomonic.  In  intestinal  colic,  the  pain  begins  at  the  um- 
bilicus, and  radiates  over  the  abdomen.  In  gall-stone  colic,  the 
pain  has  its  seat  at  the  free  border  of  the  ribs,  and  shoots  to  the 
back  and  upward  to  the  right  shoulder.  In  intestinal  colic,  pres- 
sure relieves  the  pain;  in  gall-stone  colic  it  aggravates  it.  In 
intestinal  colic  the  pain  is  intermittent;  in  gall-stone  colic  it  is 
constant,  though  j>aroxysinal.  In  intestinal  colic,  jaundice  is 
never  present,  while  it  may  exist  in  bilary  colic.  In  renal  colic, 
the  pain  shoots  from  the  region  of  the  affected  kidney  to  the 
inner  part  of  the  thigh  and  end  of  the  penis,  and  the  testicles  are 
retracted;  in  gall-stone  colic  the  direction  of  the  pain  is  upward 
and  backward.  In  renal  colic,  there  is  a  constant  desire  to  mic- 
turate. There  is  no  urinary  disturbance  in  biliary  colic 
(Loomis). 

Prognosis. — Oft  repeated  attacks  of  biliary  colic  are  bad. 

Treatment. — Relieve  the  pain  by  morphine  hypodermically, 
inhalations  of  chloroform  or  ether;  two  or  three  leeches  over  the 
gall-bladder  is  often  followed  by  relief.  Large  draughts  of  warm 
water,  containing  bicarbonate  of  soda  often  relieves  the  pain. 
Wrap  warm  clothes  around  the  abdomen.  If  there  are  signs  of 
collapse,  give  stimulants  (Loomis).  A  gall-stone  patient  must 
not  have  wine  or  fats.  He  must  exercise  in  the  open  air.  A 
prolonged  course  of  alkaline  mineral  water  has  been  found  the 
best  remedy  against  the  formation  of  gall-stones.  Ether,  turpen- 
tine, chloroform  and  hydrate  of  chloral  have  been  projDosed  as 
specifics,  it  being  thought  they  have  the  power  of  dissolving  the 
gall-stones.  According  to  Bartholow,  the  most  effective  remedy 
for  the  removal  of  the  conditions  which  lead  to  the  formation  of 
biliary  calculi,  or  to  bring  about  their  solution,  is  sodium  phos- 
phate. He  prescribes  this  in  drachm  doses,  three  times  daily, 
dissolved  in  sufficient  hot  water,  and  taken  before  meals.  This 
remedy  is  continued  for  several  weeks  or  months.  Vichy  water 
should  be  used. 


92  A    COMPENDIUM    OF    PRACTICAL     MEDICIJNTE. 

PRESCRIPTIONS  FOR  BILIARY  CALCULI. 

J&      Sodii  bicarbonatis 3v. 

In  chartas  no.  xx  div. 
Sig. :     One  powder  three  times  daily  for  several  months  (Prophy- 
lactic). — Alonzo  Clark. 

J&      Chloroformi §iv. 

Sig. :     To  be  inhaled,  a  small  quantity  at  a  time  until  paroxysm 
ceases.  — Ringer. 

Jfc     Sodii  phosphatis 3ss-iss. 

In  chartas  no.  xx  div. 

Sig. :     A  powder  before  each  meal  continued  for  months   (Pro- 
phylactic). — Bartholow. 

|fc     Olei  olivse  optim Oj. 

Sig. :     To  be  taken  in  divided  doses  before  breakfast. 

|£     Morphinse  sulphatis gr.  -i-J. 

Atrophia?  sulphatis gr.  T^ 

Aquee q.  s. — M. 

Sig.;     To  be  injected  hypodermically  during  the  paroxysm,  and 
repeat  if  necessary.  — Bartholow. 

CALCULI.     (Renal). 

Renal  calculi  are  concretions  formed  by  precipitation  of 
certain  substances  from  the  nrine  about  some  body  or  material 
acting  as  a  nucleus  (Bartholow).  They  may  be  deposited  in  the 
tubes  of  the  pyramids,  in  the  cortical  "substance,  or  in  the  pelvis 
of  the  kidney.  By  far  the  most  frequent  variety  is  uric  acid. 
Oxalate  of  lime  may  form  the  starting  jjoint  of  uric  acid  de- 
posits. Phosphatic,  next  touric,  are  the  most  frequently  encoun- 
tered calculi.  Mixed  calculi  are  common.  They  vary  in  number. 
A  kidney  may  contain  one  or  a  large  number  of  concretions. 
They  vary  in  size  from  a  pin's  head  to  a  hazel  nut;  the  larger 
ones  may  fill  the  whole  pelvis;  the  smallest  constitute  "kidney 
gravel."  If  the  larger  ones  obstruct  the  ureters,  they  become 
the  cause  of  pyelitis,  pyonephrosis,  hydronephrosis,  or  abscess 
(Loomis). 

Causes. — Renal  calculi  occur  at  all  ages,  and  are  very  fre- 
quent in  children  before  the  fifth  year,  and  from  five  to_fifteen. 


CALCULI.  93 

Males  are  nmch  more  liable  to  them  than  females.  A  sedentary 
life  favors  their  development.  The  nuclei  of  renal  calculi  may 
he  pus,  blood,  epithelium,  or  grains  of  pigment. 

Symptoms. — Usually  there  is  an  aching  pain  in  the  lumbar 
region  and  loins,  which  frequently  shoots  into  the  testicles,  or 
labia,  and  down  the  inner  side  of  the  thighs;  an  itching  at  the 
end  of  the  penis,  and  a  frequent  desire  to  urinate.  The  urine 
often  contains  pus,  blood  and  tailed  epithelium.  The  passage  of 
a  calculus  along  the  ureter  into  the  bladder  is  marked  by  sudden 
and  intense  pain  in  the  region  of  the  affected  kidney,  and  is 
called  renal  colic.  The  urine  is  scanty  or  suppressed,  and  what 
is  passed  is  of  a  smoky,  high  color,  often  bloody,  and  is  dis- 
charged in  drops,  with  a  painful,  burning  sensation.  The  testi- 
cle of  the  affected  side  is  retracted.  When  the  calculus  is  washed 
into  the  ureter,  an  atrocious  pain  suddenly  seizes  the  patient, 
who  cries  out,  rolls  from  side  to  side,  or  rushes  up  and  down  the 
room.  The  face  is  pale  and  torn  with  agony,  and  the  body  is 
covered  with  a  cold  sweat.  There  may  be  nausea  or  vomiting, 
syncope  or  convulsions.  The  thigh  of  the  affected  side  is  be- 
numbed (Bartholow).  The  paroxysm,  after  some  minutes  or 
hours,  usually  terminates  suddenly  by  the  escape  of  the  stone 
into  the  bladder.  If  the  calculus  become  impacted  in  the  ureter 
it  will  ulcerate  through  and  give  rise  to  a  fatal  peritonitis. 
Gravel  may  occasion  no  distress  at  all,  or  at  most  some  little 
burning  at  micturition.  After  the  passage  of  a  calculus  into 
the  bladder,  it  will  soon  be  found  in  the  urine  voided,  or  remain- 
ing in  the  bladder,  it  increases  in  size,  and  forms  a  vesical  calculus. 

Diagnosis. — By  remembering  the  diagnostic  points  the  diag- 
nosis is  easy. 

Prognosis. — Usually  good. 

Treatment. — To  relieve  renal  colic,  give  morphine  hypo- 
dermically,  warm  baths  and  hot  poultices  to  the  loins  and  abdo- 
men. Inhalation  of  ether  or  chloroform  will  give  relief.  If 
gravel  or  sand  of  uric  acid  is  present,  probably  the  best  prepara- 
tion is  the  officinal  liquor  potassii  citratis,  of  which  a  table - 
spoonful  may  be  taken  every  three  hours  (Bartholow).  The 
faithful  use  of  alkaline  water  not  only  delays,  but  often  arrests 
the  formation  of  renal  calculi  (Loomis).     The  Lithia,  Carlsbad, 


94  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Vicliy  or  Ems  waters  are  efficacious.  In  five-sixths  of  the  cases 
the  urinary  concretions  consist  of  uric  acid,  and  this  forms  the 
red  sand  which  quickly  collects  around  the  sides  and  bottom  of 
the  vessel  containing  the  urine.  The  urine  in  these  cases  is 
always  acid.  In  cases  of  uric  acid  gravel,  the  urine  is  too  con- 
centrated. The  alkaline  remedies  above  are  indicated,  with  a 
large  amount  of  water.  The  concretions  may  consist  of  the 
earthy  salts,  namely,  the  phosphate  of  ammonia  and  magnesia, 
and  the  phosphate  and  carbonate  of  lime.  Ammonio-magnesian 
calculi  are  liable  to  form  in  cases  of  cystitis.  These  concretions 
are  generally  not  renal  but  vesical.  The  urine  in  these  cases  is 
usually  alkaline,  and  the  mineral  acids  are  indicated,  either  the 
sulphuric  or  hydrochloric.  The  nitro- hydrochloric  acid  is  espec- 
ially indicated  in  cases  of  oxalate  of  lime  gravel.  The  ingestion 
of  large  quantities  of  water  form  a  highly  important  part  of  the 
treatment  in  all  cases  of  gravel. 

PRESCRIPTIONS  FOR  RENAL  AND  VESICAL  CALCULI. 

IJ     Liquoris   potassee 5ij. 

Infusi  buch  u 3  viij  • — M. 

Sig. :     Three  tablespoonsful  an  hour   after  meals.  (When  urine 

acid.)  — Reese. 

R     Lithii    citratis Sss. 

Syrupi  aurantii  cort Sj- 

Aquae ad Siij. — M. 

Sig. :     A  tablespoonful  in  a  wineglass  of  water  three  times  daily. 

-Guy. 

5     Magnesii  carbonatis 5j- 

Sodii  biboratis 

Acidi  citrici aa 5ij  • 

Aquae  bullientis Sviij. — M. 

Sig.:    A  tablespoonful  three  or  four  times  daily.     (When  urine 
acid).  — Bartholow. 

R     Acidi  nitrici  diluti 

Acidi  hydrochlorici  diluti aa...5iij- 

Syrupi  auranti  cort 

Aquse  aurantii  flor .aa 3j. 

Aquae  destillatae Sxiiiss. — M. 

Sig.:     A   wineglassful  three  or  four  times  daily.     (When  urine 
alkaline).  — Druitt. 


CARCINOMA.  95 

R     Acidi  nitrici  diluti  

Acidi  hydrochlorici  diluti  aa 2JtxL 

Infusi  serpentarise 5  viij . — M. 

Sig. :     A  half  wineglassful  three  times  daily.     (When  urine  alka- 
line). — Bird. 

R     Ammonii   benzoatis 5ii-iij. 

Syrupi 3  iss. 

Aqua3  ad 5yj. — M. 

Sig. :     A  tablespoonful  two  or  three    times  daily.     (When    urine 
alkaline).  — Seymour. 

R      Strychnise gr.  j. 

Acidi  nitrici  diluti 5j. 

Aquse Sxij . — M. 

Sig.:     Two  tablespoonsful  three  times  daily.     (When  urine  alka- 
line). — Bird. 

CARCINOMA,  OR  CANCER. 

Is  a  tumor  with  a  specific  arrangement  of  the  cells  in  spaces 
called  alveoli. 

Theory. — Conheini  has  advanced  the  theory  of  the  embry- 
onic origin  of  tumors,  the  germs  of  the  tumor,  perhaps  consist- 
ing of  misplaced  embryonic  cells,  are  brought  by  the  individual 
into  the  world.  They  may  remain  dormant  for  a  variable  length 
of  time,  and  then  under  the  influence  of  some  exciting  cause, 
possibly  an  injury,  may  begin  to  grow. 

Cause. — Nothing  is  definitely  known  as  to  the  origin  of 
cancer,  in  any  situation,  but  there  is  one  thing  certain,  it  is  a 
disease  of  advanced  life,  and  is  more  apt  to  appear  from  forty  to 
sixty  than  at  any  other  period. 

CARCINOMA  OF  THE  STOMACH. 

Of  all  the  organs  of  the  body,  the  stomach  is  most  frequently 
the  seat  of  cancer — more  frequently  than  the  uterus,  which 
comes,  strictly,  next.  As  regards  age,  the  majority  of  cases  occur 
at  fifty,  but  the  disease  may  appear  at  any  time  from  forty -five 
to  sixty.  It  is  very  rare  from  thirty  to  forty  (Bartholow).  Ac- 
cording to  Loomis,  the  stomach,  next  to  the  liver,  is  the  most 


96  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

frequent  seat  of  internal  cancer;  one -third  of  all  the  cases  of 
primary  cancer  have  their  seat  in  the  stomach.  According  to 
Welch,  quoted  by  Flint,  the  stomach,  next  to  the  uterus,  is  the 
most  frequent  seat  of  primary  carcinoma. 

Cause. — Hereditary  predisposition  is  undoubtedly  its  most 
important  etiological  factor.  Beyond  this  its  etiology  is  obscure 
(Loomis). 

Symptoms. — Anorexia,  nausea,  vomiting,  pyrosis,  soreness 
over  the  stomach  are  the  earliest  symptoms.  After  a  time  the 
pain  becomes  lancinating,  fixed  and  constant.  There  are  three 
prominent  causes  of  the  vomiting :  First,  from  obstruction. 
When  the  obstruction  is  at  the  cardiac  orifice,  vomiting  occurs 
immediately  after  eating  ;  when  at  the  pylorus,  the  food  is  re- 
tained for  one  or  two  hours.  Second,  from  irritation.  Third, 
from  fermentation.  The  absence  of  hydrochloric  acid  from  the 
gastric  juice  is  held  to  be  an  infallible  sign  of  cancer.  When 
the  cancer  ulcerates,  the  most  constant  symptom  is  hemorrhage 
("coffee -ground"  vomit).  The  stools  have  a  dark,  tarry  appear- 
ance. Emaciation,  debility,  haggard  look,  and  yellow  skin  are 
often  present.  By  palpation,  a  hard,  irregular  and  nodulated 
tumor  may  be  discovered. 

Differential  Diagnosis. — Cancer  of  the  stomach  may  be  mis- 
taken for  gastric  ulcer,  and  abdominal  aneurism.  Ulcer  of  the 
stomach  occurs  most  in  young  adults,  especially  females,  while 
cancer  is  seldom  met  with  in  persons  under  forty.  In  cancer 
there  is  usually  a  history  of  hereditary  cancer.  The  pain  in 
cancer  is  continuous,  and  described  as  lancinating ;  while  in 
ulcer  the  pain  is  intermittent,  greatly  increased  by  taking  food. 
Hsematemesis,  in  cancer,  has  a  sooty  or  "coffee -ground"  appear- 
ance, is  small  in  amount,  and  appears  late  in  the  disease,  while 
in  ulcer  it  is  bright  red  arterial  blood,  is  profuse,  and  appears  as 
an  early  symptom.  Vomiting  in  cancer  does  not  relieve  the 
pain,  and  is  not  very  severe  ;  but  in  ulcer  it  is  severe,  and  relieves 
the  pain.  The  presence  of  an  epigastric  tumor  establishes  the 
diagnosis  of  cancer.  An  aneurismal  tumor  is  smooth  and  ovoid; 
a  cancerous  tumor  is  hard  and  irregular.  In  aneurism,  there  is 
an  expansile  pulsation,  while  in  cancer  this  impulse  is  lifting  in 
character  (Loomis). 


CARCINOMA.  97 

Prognosis. — Is  always  unfavorable.  Its  shortest  duration. is 
seven  weeks,  and  its  longest  three  and  one-half  years,  the  aver- 
age being  one  year  (Loomis). 

Treatment. — Is  altogether  palliative.  As  to  diet,  milk  and 
beef  juice  are  the  best.  The  burning  pain  is  much  diminished 
by  washing  out  the  stomach  once  a  day  with  the  stomach  pump. 
Bartholow  recommends  equal  parts  of  pure  carbolic  acid  and 
tincture  of  iodine,  of  which  one  or  two  drops  may  be  given  in 
water  three  times  daily.  For  the  pain,  give  morphine  hypoder- 
mically.  Arsenic,  in  the  form  of  Fowler's  solution,  one  or  two 
drops,  three  times  a  day,  has  power  to  allay  pain  and  retard  the 
growth. 

CARCINOMA  OF  THE  INTESTINE. 

Cancer  of  the  intestine  is  usually  primary.  The  rectum  is 
its  most  frequent  seat,  then  the  anus,  the  caecum,  the  sigmoid 
and  the  colon  (Loomis). 

Cause. — The  cause  is  obscure.  It  is  a  disease  of  advanced 
life  (after  forty).  Males  are  affected  three  and  a  half  times 
oftener  than  females. 

Symptoms. — There  are  pains  in  a  fixed  situation,  a  gradually 
developing  cachexia,  and  the  presence  of  a  tumor.  The  pain  at 
first  is  slight,  then  acute  and  sharp.  The  patient  declines  in 
strength  and  weight,  has  a  feeling  of  fatigue,  a  fawn- color  com- 
plexion, bluish- white  lips,  a  skin  dry,  wrinkled  and  scurfy.  In 
cancer  of  the  stomach  and  intestines  the  patients  usually  suffer 
from  a  profuse  salivary  flow  without  apparent  cause.  Constipa- 
tion is  the  rule  (Bartholow).  In  cancer  of  the  rectum,  hard 
nodular  masses  may  be  felt. 

Prognosis. — Is  always  unfavorable.  A  fatal  termination 
will  be  reached  in  a  year  or  two. 

Treatment. — The  treatment  is  only  palliative.  The  pain 
must  be  relieved  by  morphine,  hypodermically.  The  diet  should 
consist  of  milk,  nutritive  broths,  eggs,  etc.  Arsenic  may  relieve 
the  pain  and  retard  the  growth  (Bartholow).  The  formation  of 
an  artificial  anus  is  a  surgical  means  of  prolonging  life. 


98  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

CARCINOMA  OF  THE  LIVER. 

Cancer  of  the  liver  may  be  either  primary  or  secondary.  It 
is  secondary  to  cancer  of  the  stomach  in  one -half  of  the  cases.  It 
has  been  estimated  that  one  out  of  every  one  hundred  persons 
has  cancer  of  the  liver  (Loomis). 

Cause. — The  cause  is  unknown.  Hereditary  predisposition 
exists  in  most  cases.  It  occurs  most  often  between  the  ages  of 
40  and  65.  Medullary  cancer  of  the  liver  sometimes  occurs  in 
early  life. 

Symptoms. — The  patient  gradually  loses  flesh  and  strength, 
complains  of  a  sense  of  weight  and  fullness  in  the  region  of  the 
liver.  The  pain  soon  becomes  lancinating,  and  is  localized  at 
some  j3oint  over  the  liver,  which  is  tender  to  pressure.  There  is 
loss  of  appetite,  flatulence,  nausea,  vomiting.  Jaundice  is  pres- 
ent in  one-half  of  the  cases.  Ascites  occurs  more  frequently  than 
jaundice.  (Edenia  of  the  feet  comes  on  late.  The  temperature 
is  normal  or  sub-normal.  Palpation  discloses  an  enlarged  liver, 
tender  to  pressure,  with  hard,  smooth  nodules  over  its  surface 
(Loomis). 

Prognosis. — Cancer  of  the  liver  is  a  fatal  disease.  The  aver- 
age duration  is  about  one  year  (Loomis). 

Treatment. — Is  palliative.  Regulate  the  diet.  Relieve  the 
pain  by  a  hypodermic  of  morphine.  There  is  no  remedy  for 
cancer  in  any  situation.  Ascites  will  require  attention  by  tap- 
ping. 

CARCINOMA  OF  THE  KIDNEY. 

Cancer  of  the  kidney  may  be  primary  or  secondary. 

Causes. — The  cause  is  obscure.  It  occurs  in  early  life,  be- 
fore five,  and  in  old  age. 

Symptoms. — There  is  gradual  emaciation,  soreness  in  the 
lumbar  region,  and  hematuria. 

Prognosis. — The  prognosis  is  always  bad.  The  termination 
is  invariably  death. 

Treatment. — Is  palliative.  Relieve  the  pain  and  sustain  the 
patient. 


CARCINOMA CARIES.  99 

CARCINOMA  OF  THE  LUNG. 

Cancer  of  the  lnng  is  usually  secondary,  and  very  often  suc- 
ceeds to  cancer  of  the  breast  removed  by  amputation.  It  may  be 
primary,  but  rarely  so.  It  is  a  disease  of  advanced  life  and  is 
extremely  rare  before  forty  (Bartholow). 

Cause. — The  cause  is  obscure.  Hereditary  predis230sition  is 
a  most  influential  factor. 

Symptoms. — There  is  usually  pain  in  the  chest  and  a  cough 
accompanied  by  a  muco -hemorrhagic  expectoration  resembling 
currant  jelly  (Loomis).  There  is  dyspnoea,  emaciation,  fever, 
night- sweats,  with  failure  of  strength,  and  haemoptysis. 

Prognosis. — Is  always  unfavorable. 

Treatment. — Is  altogether  palliative,  and  is  restricted  to  the 
relief  of  symptoms. 

CARCINOMA  IN  OTHER  ORGANS. 

Cancer  of  the  arteries,  brain,  gall-bladder,  heart,  tongue, 
larynx,  oesophagus,  mediastinum,  pancreas,  pericardium,  plura, 
and  spleen  is  met  with.  In  some  cases  it  is  primary,  in  others 
secondary.  The  cause  is  obscure.  The  prominent  symptoms 
are  pain,  the  cancerous  cachexia,  and  a  tumor.  The  prognosis  is 
unfavorable,  and  the  treatment  is  only  palliative. 

CARIES. 

Is  inflammation  and  ulceration  of  bone;  while  necrosis  is 
its  death  en  masse.  Bones  of  spongy  texture  are  more  frequently 
attacked  by  caries  than  such  as  are  compact.  The  bones  of 
young  persons  are  more  often  the  seat  of  caries  than  those  of  old 
subjects.  On  examination,  the  bone  is  found  to  be  soft  and  dark 
red;  its  cells  are  filled  with  a  reddish,  serous,  glary  fluid,  or  with 
soft  granulations  of  feeble  vitality.  It  is  always  vascular  and 
readily  bleeds  on  being  touched.     It  is  occasionally  painful. 

Causes. — The  predisposing  cause  is  some  constitutional  dis- 
order, scrofula,  or  syphilis.  The  exciting  cause  may  be  a  blow 
or  injury. 


100  a  compendium:  of  practical    medicine. 

Treatment. — Correct  trie  constitutional  disorder  and  give 
tonics,  fresh  air  and  baths.  The  usual  remedies  employed  in 
scrofula  and  syphilis  are  indicated.  Locally,  the  best  treatment 
is  to  freely  expose  and  remove  the  diseased  portion  of  bone. 

PRESCRIPTIONS  FOR  CARIES. 

B     Cupri  sulphatis 

Zinci  sulphatis aa  partes xv. 

Liquoris  plumbi  subacetatis 

partes xxx. 

Aceti partes CC. — M. 

Sig. :     To  be  injecd  through  the  sinuses.  — Villate- 

B     Syrupi  calcis  lactophosphatis ^viij . 

Sig. :     A  dessertspoonful  to  a  tablespoonful  three  times  daily. 

—  Bartholow. 
Cod-liver  oil  should  be  given  to  promote  constructive  meta- 
morphosis (Bartholow). 

CARBUNCLE.     (See   Anthrax). 

CATARRH  (Nasal,  called,  also,  Coryza). 

Is  a  catarrhal  inflammation  of  the  nasal  mucous  membrane. 
It  is  commonly  called  "cold  in  the  head." 

Causes. — Atmospherical  causes  are  the  most  frequent  and 
influential.  The  exjDosure  of  the  neck  to  a  current  of  cold  air, 
of  the  feet  and  ankles  to  cold  and  dampness,  passing  from  a 
warm  to  a  cold  atmosphere,  and  from  a  cold  to  a  warm  atmos- 
jxhere  suddenly,  are  among  the  most  usual  causes.  Irritating 
gases  and  vapors  or  dust  may  cause  coryza.  Epidemic  influence 
now  and  then  prevails  on  an  extensive  scale  (Bartholow). 

Symptoms. — Taking  cold  in  the  head  is  announced  by  chilli- 
ness, weariness,  headache,  and  general  muscular  soreness.  An 
intense  hypera?mia  is  the  first  change,  with  an  arrest  of  secretion. 
This  is  soon  followed  by  swelling  of  the  membrane,  and  the 
nose  feels  dry,  stuffed  and  uncomfortable,  and  an  inclination  to 
sneeze  is  often  felt.  Presently  the  nose  pours  out  an  abundant 
watery  and  saline  discharge.  The  discharge  soon  assumes  a 
purulent   character.     The   voice   has   a  nasal   tone.     The  acute 


NASAL    AND    FAUCIAL    CATARRH.  101 

form  terminates  in  fourteen  days.  The  chronic  may  last  for 
years.  The  discharge  of  the  chronic  form  consists  of  greenish, 
offensive  pus,  or  scales.  If  the  mucous  membrane  is  destroyed 
"by  ulcerations,  and  caries  of  the  bone  has  occurred,  the  case  is 
then  called  ozsena  (Bartholow). 

Treatment. — Where  there  is  a  strumous  diathesis  cod-liver 
oil.  the  phosphates,  iodide  of  iron,  etc.,  should  be  employed. 
Try  to  abort  an  acute  attack  by  the  administration  of  a  full  dose 
of  quinine  (gr.  xv.)  and  morphine  (gr.  ss.)  for  an  adult.  When 
established,  the  best  remedy  is  Lugol's  solution,  liquor  iodi  com- 
230situs,  one  drop  every  hour  or  two.  If  there  is  fever,  one  drop 
of  tincture  of  aconite  root  every  hour  will  prove  efficient.  If  the 
secretion  is  watery  and  profuse,  tincture  of  belladonna  may  be 
given  with  the  aconite,  two  drops  every  two  hours.  In  the  local 
treatment  of  chronic  catarrh,  the  post-nasal  syringe  and  tepid 
water  containing  a  little  common  salt  are  the  best  materials  for 
cleansing  the  passage.  The  tincture  of  iodine  and  carbolic  acid 
may  be  readily  volatilized  and  inhaled  from  a  small  bottle.  A 
cocaine  tablet  containing  gr.  i-i  in  the  form  of  a  flattened  disc, 
introduced  alongside  the  septum,  one  on  each  side,  twice  or  three 
times  daily,  is  more  successful.  Very  dilute  solutions  of  chlorate 
of  potassa,  chloride  of  ammonium,  sulphates  of  zinc,  cadmium 
and  copper,  and  acetate  of  lead,  may  be  tried  (Bartholow). 

According  to  Bartholow,  the  most  effective  application  is  a 
powder  composed  of  tannin  and  iodoform  (5i.-gr.  x.)  applied 
by  means  of  an  insufflator.  Dobell's  is  an  efficacious  cleansing 
solution  in  chronic  nasal  catarrh,  hypertrophic  nasal  catarrh, 
atropic  nasal  catarrh,  and  fetid  nasal  catarrh  (ozsena). 

PRESCRIPTIONS  FOR  NASAL  AND  FAUCIAL  CATARRH, 

J&     Cocaine  muriate gr.  vj 

Bismuthi  subcarbonatis 5ss. 

Talc 5iss.— M. 

Sig. :     Enough  to  cover  a  silver  five  cent  piece,  insufflated  into 
each  nostril  every  two  hours.     (For  acute  coryza).  — Sajous. 

Jfc     Tinctura?  aconiti  radicis 3J. 

Tincturse  Belladonna? ,  .31). — M. 

Sig.:     Three  drops  every  hour.      (Pharyngitis   and    acute  ton- 
silitis).  — Ringer. 


102  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

j&     Chloroformi 5ij- 

Glycerinse 

Spiritus  vini  galici aa Sj  • — M. 

Sig.:     One  teaspoonful  in  water  every  three  hours.     (For  acute 
coryza). '  — Sajous. 

|fc     Acidi  carbolici  liq ITtxxx. 

Sodii  biboratis 

Sodii  bicarbonatis aa 5j  • 

Glycerinse oiiiss. 

Aquse q.  s.,  ad.,  ft Siv. — M. 

Sig.:     To  be  used  with  atomizer.     (Simple  chronic  rhinitis). 

— Dobell. 

|fc     Sodii  bicarbonatis Sj- 

Sig. :     Insufflate  or  apply  with  the  finger  to  the  inflamed  tonsil. 
(Tonsilitis.)  — Gine. 

|fc     Resorcin gr.  v.-x. 

Aquse  destillatse o ij • — M. 

Sig.:     Used  with  atomizer  twice  daily,  four  minutes  each  time. 

— Masini  and  Massei. 

CATARRH.     (Chronic  Gastric.) 

Causes. — In  many  persons  there  is  an  hereditary  tendency 
after  middle  life,  to  chronic  gastric  catarrh.  The  principal  gen-' 
eral  cause  of  this  affection  is  anaemia.  The  most  common  local 
cause  is  the  daily  use  of  alcoholic  stimulants.  Diseases  of  the 
liver,  heart  and  lungs  which  offer  an  obstacle  to  the  venous 
return,  will  induce  chronic  gastric  catarrh.  Highly- seasoned 
foods,  condiments,  sauces,  hasty  and  insufficient  mastication,  the 
frequent  use  of  ices,  and  overfeeding  are  the  principal  causes. 
The  prolonged  use  of  arsenic,  mercury,  cubebs  and  purgatives 
often  causes  it.  Finally,  scrofula,  syphilis  and  gout  predispose 
to  it  (Bartholow  and  Loomis). 

Symptoms. — After  taking  food,  the  patient  has  a  feeling  of 
weight,  or  fullness,  sometimes  of  pain.  Sometimes  when  the 
stomach  is  empty,  sometimes  when  it  is  full,  the  pain  is  greater. 
The  symptoms  of  indigestion  are  usually  present.  There  may  be 
loss  of  appetite,  nausea,  vomiting  of  acid  mucous  in  the  morning 
or  after  meals.  It  is  this  acid  material  belched  up  into  the 
oesophagus  that  causes  "heart-burn."     There  is  gaseous  disten- 


CATARRH.  103 

tion  of  the  stomach.     Palpitation,  headache,  and  vertigo  may  be 
present. 

Treatment. — Regulation  of  the  diet  is  the  most  important  in 
all  stomach  diseases.  When  the  starches,  sugars  and  fats  reach 
the  stomach,  fermentation  begins.  To  exclude  these  articles, 
then,  is  the  first  step  toward  a  cure.  A  curative  measure  of  the 
highest  importance  is  the  "skim-milk  cure,"  which  consists  in 
the  exclusive  use  of  milk,  about  four  ounces  every  three  hours, 
for  some  time.  The  stomach  pump  is  very  effective  for  cleansing 
the  stomach  in  these  cases.  One  or  two  drops  of  Fowler's  solu- 
tion, three  times  daily  before  meals,  continued  for  a  month  or 
more,  is  a  remedy  of  the  highest  importance.  When  there  is 
much  acidity  it  may  be  checked  by  muriatic  acid  given  before 
meals.  Carbolic  acid  alone  or  with  bismuth  relieves  the  fermen- 
tation and  gaseous  eructations  (Bartholow). 

PRESCRIPTIONS  FOR  CHRONIC  GASTRIC  CATARRH, 

Jfc     Liquoris  potassii  arsenitis Sss. 

Sig. :     One  or  two  drops  before  meals.     (Vomiting  of  drunkards.) 

— Bartholow. 

{&     Extracti  hydrastis  fluidi Sss. 

Sig.:     Five  to  fifteen  drops  before  meals  in  water, to  be  continued 
some  time.  — Bartholow. 

{fc     Tincturse  cinchonas  comp ,..Siv. 

Tincturse  capsici 5ss. 

Tincturse  mucis  vomicae oij- — M. 

Sig.:     A   teaspoonful  every  two   or  three  hours.     (To  allay  the 
craving  for  alcohol.)  — Loomis. 

J&     Tincturse  opii  dedoratse gtt.  xvj. 

Bismuthi  subnitratis 3ij- 

Syrupi  simplicis 5iv. 

Aquse  cinnamomi 5iss. — M. 

Sig.:     Shake   bottle.     Give   one   teaspoonful  every   two  to  four 
hours.     (For  child  one  year  old.)  — J.  Lewis  Smith. 


104  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

CHANCRE. 

I.  Induration  of  Syphilitic  Chancre. — Can  always  be  felt 
when  present,  and  in  well  marked  cases  it  is  absolutely  pathogno- 
monic. It  exists  in  three  varieties  :  1.  A  thin  superficial  layer 
of  induration,  aptly  called  '"■parchment-like,"  exactly  underlying 
the  ulceration.  This  is  the  commonest  form.  2.  The  induration 
may  resemble  a  split  pea,  situated  exactly  beneath  the  ulcer, 
which  is  upon  its  flat  surface.  This  induration  is  easily  felt,  is 
little  or  not  at  all  sensitive,  freely  movable  over  the  rjarts 
beneath,  hard  like  bone  or  wood,  feels  elastic,  is  sharply  defined, 
ends  abruptly.  3.  The  induration  may  be  very  extensive,  far 
surpassing  the  bounds  of  the  ulceration  placed  upon  it,  exca- 
vated or  convex  upon  its  surface.  The  skin  over  it  is  not  usually 
red.  Induration  is  usually  greatest  in  chancres  of  the  skin,  lips, 
nipples,  behind  the  corona  glandis,  and  near  the  fraenum  of  the 
penis.  In  spongy  tissue  like  the  glans  penis,  the  induration  is 
often  very  slight.  Again,  when  a  syphilitic  chancre  becomes 
phagedenic,  it  loses  its  induration  at  once.  The  induration  may 
precede  the  ulceration  or  follow  it.  In  the  latter  case  it  comes 
on  during  the  first  week.  Usually  any  form  of  induration  will 
outlast  the  ulceration,  remaining  for  two  or  three  months,  or 
more  rarely  for  years.  Eicord  records  one  case  of  thirty  years 
standing  (Keyes). 

II  Ulceration  of  Syphilitic  Chancre. — Properly,  syphi- 
litic chancre  does  not  ulcerate.  It  consists,  in  more  than  half  the 
cases,  simply  of  an  excoriated  surface,  looking  red  and  bloody, 
very  superficial,  frequently  scabbed  when  exposed  to  the  air. 
Indeed,  it  may  never  even  excoriate,  the  lesion  consisting  in  a 
simple  indurated  tubercle,  which  scales  off  a  little  at  the  top. 
But  chancre  of  the  genitals  rarely  escapes  more  or  less  inflam- 
mation, hence  it  is  the  rule  to  find  some  shallow,  occasionally 
deep,  ulceration.  When  shallow,  the  ulcer  is  round  or  oval, 
with  slanting  borders,  often  a  red  base.  When  deep,  the  borders 
are  never  abrupt,  as  in  chancroid,  but  always  sloped  off.  The 
cavity  is  funnel-shaped.  Sometimes  the  induration  left  behind 
on  the  healing  of  a  chancre  re- ulcerates  (Keyes). 


CHANCRE.  105 

III.  Character  of  the  Discharge. — Pus  does  not  form  as 
such  on  true  syphilitic  chancre,  unless  it  be  inflamed.  Ordinarily 
the  discharge  is  sero- purulent  or  purely  serous,  often  bloody 
(Keyes). 

IV.  Pain. — In  unirritated  syphilitic  chancre,  as  a  rule, 
there  is  absolutely  no  pain.  A  patient  often  carries  a  chancre 
some  time  without  knowing  it,  and  sometimes  it  comes  and  goes 
without  being  discovered  at  all.  In  this  way  may  be  explained 
many  singular  cases  of  undoubted  syphilis,  apparently  not  pre- 
ceded by  any  primary  lesion  (Keyes). 

V.  Cicatrix. — The  scar  left  by  chancre  varies.  In  a 
number  of  cases,  there  is  no  scar  left  behind.  The  scars  left  are 
at  first  discolored,  of  a  dark,  vinous  hue,  like  the  color  of  raw 
ham.  This  color  may  be  followed  by  the  true  coj)per- colored. 
The  scar  is  finally  whiter  in  the  center  than  the  surrounding 
skin  (Keyes). 

VI.  Inoculation. — Auto -inoculations  of  chancre -secretion 
have  been  performed  without  number,  the  result  having  been 
invariably  negative,  unless  the  chancre  had  been  previously  irri- 
tated, or  producing  pus.  Under  such  circumstances,  the  pustule 
and  ulceration  produced  would  be  the  same  as  the  pus  of  any 
indifferent  abscess  would  cause.  The  difference  between  the 
inoculation  of  chancroid  and  syphilitic  chancre  is  illustrated  in 
the  famous  case  of  Lindmann,  who  inoculated  himself  a  number 
of  times  with  chancroid  pus,  always  with  success,  but  with  no 
syphilis;  finally,  believing  himself  protected  (/.  <?.,  syphilized), 
he  inoculated  himself  with  matter  taken  from  the  ulcerated 
tonsils  of  a  syphilitic  friend.  This  was  followed  on  the  eleventh 
day  by  a  papule.  The  papule  ulcerated  slightly,  and  in  forty- 
five  days  a  general  syphilitic  eruption  appeared.  Lindmann 
inoculated  himself  twenty- seven  hundred  times  with  chancroid 
matter.  Warnery,  under  the  same  "  syphilization "  delusion, 
inoculated  himself  many  times  with  chancroid  matter,  which 
took,  but  produced  only  local  ulcers.  Finally  he  employed  the 
syphilitic  virus  once,  and  an  indurated  chancre  appeared,  after 
twenty- seven  days  incubation,  followed  by  syphilis  in  due  course. 
Danielssen,  a  believer  in  "syphilization,"  inoculated  a  man,  who 
had    elephantiasis,   two   hundred    and    eighty- seven   times   with 


106  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

chancroid;  after  this  it  would  not  take  (i.  ^.,  lie  was  "syphiL 
ized").  Now,  one  inoculation  was  made  with  true  syphilitic 
virus.  An  indurated  syphilitic  chancre  appeared,  and  in  sixty- 
eight  days  a  general  syphilitic  eruption  followed  (Keyes).  The 
course  of  syphilitic  chancre  observed  by  hetero- inoculation  is  as 
follows  :  "There  may  be  a  pustule  which  soon  heals.  No  change 
occurs  for  a  period  varying  from  ten  to  thirty- nine  days;  then 
the  first  signs  of  chancre  appear,  not  as  in  chancroid  by  a 
pustule,  but  as  an  indurated  papule  of  a  dark  color  without 
pain,  followed  by  syphilis. 

There  is  one  source  of  error  in  regard  to  vaccinal  syphilis ; 
namely,  that  the  vaccinal  fever  may  develop  latent,  possibly  un- 
suspected syphilis  from  which  a  child  is  already  suffering  by 
inheritance,  or  previous  contagion.  Here  the  vaccination  will 
always  be  accused  of  being  the  cause  of  syphilis.  The  distinc- 
tion is  easy.  If  vaccination  develops  latent  syphilis,  it  does  so 
as  a  blister  would,  and  a  general  eruption  comes  on  quickly; 
whereas  in  true  vaccinal  syphilis,  there  is  first  a  period  of  incuba- 
tion, then  a  local  chancre,  then  indurated  glands,  and  after  a 
second  incubation,  a  general  syphilitic  eruption  (Keyes). 

VII.  Duration  of  Syphilitic  Chancre . — Is  from  two  weeks 
to  several  months.  In  about  fifty  per  cent,  of  the  cases  a  general 
syphilitic  eruption  appears  before  the  chancre  has  cicatrized. 

VIII.  Number. — Syphilitic  chancre  is  most  often  unique, 
because  commonly  only  one  point  is  inoculated.  When  multiple, 
however,  it  is  usually  so  from  the  first,  because  its  secretion  is 
not  auto-inoculable. 

IX.  Size. — Syphilitic  chancre  may  occasionally  reach  a 
large  size,  as  large  as  a  quarter  or  a  half  dollar.  This  is,  how- 
ever, exceedingly  rare.  It  is  often  as  small  as  a  split  pea  and 
sometimes  smaller.  In  size  and  general  appearance  it  compares 
unfavorably  with  its  more  formidable-looking  rival,  chancroid. 

X.  Situation. — Syphilitic  chancre  occurs  indifferently  on 
all  points  of  the  body.  No  regions  are  exempt  from  it.  Syph- 
ilitic chancres  of  the  head,  face  and  breast  are  common,  and  reach 
their  full  size.  Chancre  of  the  lip  is  particularly  prominent, 
large,  hard,  and  chronic  in  its  course.  The  genitals  are  the 
favorite  seat,  because   they  are    most  often  exposed.     Urethral 


CHANCRE.  107 

chancre  is  not  very  common.  It  may  simulate  gonorrhoea  in  its 
discharge,  but  when  the  eruption  appears,  the  diagnosis  will  be 
easy. 

XI.  Form  of  Syphilitic  Chancre. — Syphilitic  chancre 
appears  after  an  incubation  of  not  less  than  ten  days,  usually  not 
till  the  end  of  three  weeks,  as  a  reddened  spot,  which  quickly 
excoriates ;  or  as  an  elevated  papule,  which  excoriates  or  ulcer- 
ates. It  may  take  any  one  of  four  forms,  in  the  following  order 
of  frequency:  1.  Erosion.  2.  Ulceration.  3.  Deep  ulceration, 
funnel  shaped  (Hunterian  chancre).  4.  Indurated  papule,  which 
remains  dry.  Erosion  is  believed  to  include  two -thirds  of  all 
syphilitic  chancres.  It  is  very  common  inside  of  the  prepuce. 
It  discharges  serum  and  not  pus.  The  indurated  papule,  which 
does  not  ulcerate,  is  found  sometimes  on  the  skin  after  inocula- 
tion, and  even  on  the  mucous  layer  of  the  prepuce.  The  color 
of  these  papules  is  a  dark  vinous  red.  The  course  of  all  the 
above  chancres  is  about  the  same.  Chancre  uninnaniecl  and 
unirritated  is  painless  (Keyes). 

XII.  Complications  of  Syphilitic  Chancre:  Are  (a)  veg- 
etations; (b)  inflammation ;  (o)  chancroid,  mixed  chancre;  (77) 
transformation  into  mucous  patch;  (7)  phagedena  and  gan- 
grene; (f)  syphilitic  bubo;  (g)  lymphangitis. — -(a)  Vegeta- 
tions: Warty  growths  are  liable  to  spring  up  around  syphilitic 
chancre  of  the  prepuce  or  anus,  as  they  are  with  other  forms  of 
irritative  disease  (chancroid,  balanitis,  gonorrhoea).  These  are 
rare  and  purely  accidental.  Syphilis  as  a  poison  has  nothing  to  do 
with  their  production,  (c)  Chancroid  may  complicate  syphilitic- 
chancre  and  produce  a  "mixed  sore."  This  sore  will  have  the 
characters  and  qualities  of  both  lesions.  For  syphilitic  bubo, 
as  a  complication,  see  Bubo.  Syphilitic  Lymphangitis  is  a  spe- 
cific induration  of  the  lymph  vessels  and  surrounding  cellular 
tissue.  Hard,  smooth  and  knotty  cords,  varying  from  the  size 
of  a  knitting-needle  to  that  of  a  goose-quill,  can  be  felt  under 
the  skin  of  the  penis.  They  are  not  sensitive  to  pressure,  and 
the  skin  over  them  is  not  red.  Starting  in  the  induration  of  the 
chancre,  they  often  do  not  reach  to  the  root  of  the  penis.  There 
may  be  one  or  more  of  these  cords  on  one  or  both  sides  of  the 
penis.     It  occurs  in  about  twenty  per  cent  of  cases. 


108  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

XIII.     Differential  Diagnosis  of  (1)   Syphilitic    Chancre; 
(2)  Chancroid;  (3)   Herpes,   and  (4)    Ulcerated  Abrasions. — 
1.  Nature.  Of  1,  always  a  constitutional  affection.    Of  2,  always 
a  local  disease.    Of  3  and  4,  local.     2.  Cause.  Of  1,  sexual  inter- 
course with  a  patient  suffering  from  syphilitic  chancre,  or  some 
secondary  syphilitic  lesion  of  or  near  the  genitals,  vaccination 
with  syphilitic  blood,  accidental  inoculation  of  any  vehicle  con- 
taining the  syphilitic  virus  upon  an  abrasion  of  any  portion  of 
the  body.     Of  2,  sexual  intercourse  with  a  patient  suffering  from 
chancroid  of  or  near  the  genitals,  accidental  or   designed  inocu- 
lation with  the  secretion  of  chancroid.     Of  3  and  4,  mechanical 
and  chemical  irritation.     3.  Situation.    Of  the  1,   usually  upon 
or  near  the  genitals,  frequent  on  the  head,  hands  or  nipple.     Of 
the  2,  very  rare  except  on  or  around  the  genitals.     Of  the  3  and 
4,  upon  the  genitals.     4.  Incubation.    Of  the  first,  constant,  not 
less  than  ten  days,  usually  three  weeks.      Of  the  2,  none  after 
the  absorption  of  the  23oison.     Ulcer  usually  fully  formed  on  the 
second  or  third  day;  very  rarely  commences  later  than  the  sev- 
enth.    Of  the   3  and  4,  none.     5.    Commencement.     Of  the  1, 
begins  as  an   erosion   or   a  papule,  and  remains  an   erosion   or 
ulcerates.     Of  the  2,  begins  as  a  pustule  or  ulcer,  and  invariably 
remains  as  an  ulcer.     Of  the  3,  begins  as  a  group  of  vesicles, 
and  remains  as  an  ulcer.     Of  the  4,  begins  as  an  abrasion  or 
fissure,  and  remains  as  an  ulcer.     6.  Number.    Of  the  1,  usually 
unique.     Of  the  2,  usually  multiple.     Of  the  3  and  4,  generally 
multiple.     7.  lesion.    Of  the  1,  habitually  flat,  or  scooped  out, 
or  deep  funnel  shaped,  or  dry  papule.     Of  the   2,   always  true 
ulcer,  excavated,  hollowed  out.     Of  the  3,  ulcer  superficial.     8. 
Edges.  Of  the  1,  sloping  and  adherent,  sometimes  prominently 
elevated.     Of  the   2,  sharply  cut,  abrupt,  often  undermined.     9. 
Bottom.    Of  the  1,  smooth,   shining.     Of  the   2,  uneven,  warty, 
irregular,  without  luster.     10.   Color.  Of  the  1,  darkish  red,  gray 
or  black.     Of  the  2,  yellow,  tawney,  false -membranous  looking. 
11.  Secretion.    Of  the    1,   slight  sero-sanguinolent.      Of  the  2, 
abundant  and  purulent.     12.  History.    Of  the  1,  not  found  on 
persons  who  have  had  syphilis.     Of  the   2,  found  indifferently 
upon  all.     Of  the  3   and  4,   found   on  patients  with   long  and 
tight  prepuce  and  uncleanliness.     13.  InoGulability.    Of  the  1, 


CHANCRE.  109 

not  auto-inoculable.  Of  tine  2,  readily  auto-inoculable  produc- 
ing a  characteristic  chancroid  ulcer  by  the  first  day.  14.  Gourse. 
Of  the  1,  slowly  progressive.  Of  the  2,  rapidly  progressive.  Of 
the  3  and  4,  do  not  usually  tend  to  get  much  larger  than  the 
size  at  which  they  started.  15.  Sensibility.  Of  the  1,  rarely 
painful.  Of  the  2,  often  painful.  Of  the  3  and  4,  usually  painful. 

16.  Ind  itrtitioii.  Of  the  1,  constant,  parchment -like,  terminating 
abruptly,  insensitive  to  pressure,  movable  upon  the  parts  be- 
neath the  skin,  may  remain  a  few  days  or  for  years.  Of  the  2, 
absent  in  typical  cases.  When  present,  is  sensitive  to  pressure, 
shades  off  into  surrounding  tissues,  is  adherent  to  parts  around. 

17.  Bubo.  Of  the  1,  is  constant.  Of  the  2,  in  two-thirds  of  the 
cases  glands  are  unaffected.  Of  the  3  and  4,  rare.  18. 
Prognosis.  Of  the  1,  good  for  local  consequences,  but  syphilis 
follows.  Of  the  2,  no  after  affects.  Of  the  3  and  4,  good.  19. 
Treatment.  Of  the  1,  local  treatment  but  slightly  effective.  Of 
the  2,  local  treatment  curative.  Of  the  3  and  4,  local  treatment 
curative  (Keyes). 

Treatment  of  Syphilitic  Chancre. — No  amount  of  cauterization 
nor  any  local  treatment  can  prevent  the  development  of  general 
syphilis  after  the  poison  has  once  been  absorbed,  much  less  after 
the  chancre  has  appeared.  Excision  of  the  primary  lesion  does 
no  good.  The  best  local  treatment  consists  in  the  use  of  dry 
lint,  sprinkling  with  iodoform,  or  calomel,  or  the  use  of  black  or 
yellow  wash.  The  internal  treatment  of  syphilitic  chancre  is 
the  same  as  that  of  early  syphilis.  Where  there  is  the  least 
shadow  of  a  doubt,  as  to  the  diagnosis,  no  mercury  should  on 
any  account  be  given  until  an  eruption  has  appeared  (Keyes). 

PRESCRIPTIONS  FOR  CHANCRE. 

R     Hydrargyri  chloridi  mitis gr.  xv. 

Liquoris  calcis §ij. — M. 

Sig. :     Shake  and  apply  as  a  wash.     (Black  wash.)  — Bartholow. 

R     Hydrargyri  chloridi  corrosivi gr.  j. 

Liquoris  calcis 3viij-     M. 

Sig.:     Shake  and  apply  on  lint.     (Yellow  wash.)  — Little. 

R     Hydrargyri  chloridi  mitis §ss. 

Sig.:     Dust  on  and  cover  with  dry  lint. — Van  Buren  and  Keyes. 


110  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Iodoformi  

Ly  copodii — aa 5  iij  • — M. 

Sig. :     Dust  on  and  cover  with  dry  lint.  — Sturgis. 

CHANCROID. 

Is  a  local,  virulent,  contagious  venereal  ulcer,  .never  the 
starting  point  of  syphilis.  Its  own  secretions  are  freely  auto- 
inoculable. 

Of  the  three  distinct  venereal  diseases,  gonorrhoea,  chancroid 
and  syphilis — gonorrhoea  is,  strictly  speaking,  the  most  venereal, 
being  practically  never  acquired  except  in  sexual  intercourse. 
Chancroid,  equally  virulent,  is  less  venereal,  and  recognizes  many 
methods  of  propagation  besides  sexual  congress.  While  syphilis 
is  of  all  the  least  virulent,  and  the  least  venereal.  Nothing  can 
produce  chancroid  except  chancroid  (Keyes). 

Cause. — It  can  be  produced  only  by  the  contact  of  pus  from 
a  similar  ulcer  upon  some  portion  of  the  skin  or  mucous  mem- 
brane under  conditions  favorable  for  absorption.  No  one  is 
exempt.  The  bearer  of  a  chancroid  is  just  as  liable  to  be  pois- 
oned by  the  pus  of  his  own  sore  as  is  a  perfectly  healthy  person. 
Lindmann  inoculated  himself  2,700  times.  Hence  the  rule,  an 
individual  may  have  chancroid  as  often  as  he  is  exposed ;  there 
is  no  limit  to  the  number  of  possible  attacks  (Keyes). 

Frequency  of  Chancroid. — Statistics  show  that  in  dispen- 
saries and  hospitals,  among  the  poor  and  dirty,  the  frequency  of 
chancroid  far  outranks  that  of  true  syphilitic  chancre,  while  in 
the  higher  walks  of  life  true  syphilitic  chancre  is  more  common 
than  chancroid.  The  poor  consort  with  the  lower  orders  of 
prostitutes  who  have  old  chronic  chancroid,  which  forms  a  hot- 
bed of  infection  for  all  who  approach.  Finally,  syphilitic  chancre 
occurs  but  once  in  a  lifetime,  and  rarely  lasts  long ;  while  chan- 
croid may  be  acquired  an  indefinite  number  of  times. 

Methods  of  Contagion. — By  direct  contact,  as  in  sexual  in- 
tercourse, or  niani23ulation  of  chancroids  with  fissures  or  abras- 
ions on  the  hand,  or  through  some  intervening  agency. 

Situation  of  Chancroid. — It  is  rarely  found  far  from  the 
genitals.  In  the  male  by  preference  it  is  found  in  the  sulcus  on 
either  side  of  the  frgenum. 


CHANCROID.  Ill 

Symptoms. — Chancroid  has  no  period  of  incubation  or 
hatching.  When  the  virus  is  placed  in  a  position  where  absorp- 
tion is  possible,  it  commences  its  work  at  once,  and  rapidly 
reaches  the  stage  of  ulceration.  Usually  by  the  third  day  after 
suspicious  intercourse,  occasionally  as  late  as  a  week,  a  small 
ulcer  will  be  found.  It  increases  in  size  for  one  or  two  weeks, 
and  remains  stationary  for  perhaps  two  weeks,  and  then  repair  is 
announced  by  a  more  creamy,  laudable  pus.  Chancroid  is  usu- 
ally round  or  oval  in  shape.  In  number  it  may  be  unique,  or 
any  given  number  may  co- exist.  In  size,  it  varies  from  that  of 
the  head  of  a  pin  to  a  large  surface. 

Duration. — A  chancroid  untreated  never  lasts  less  than  a 
month,  and  may  last  months,  or  even  years. 

Pain. — Chancroid  may  be  almost  entirely  painless,  but 
clinically,  pain  is  usually  a  diagnostic  symptom  of  chancroid, 
serving  to  distinguish  it  from  syphilitic  chancre. 

Induration. — There  is  no  induration  unless  the  chancroid  is 
irritated,  and  then  it  is  an  inflammatory  hardness. 

Relapse. — A  chancroid  may  be  almost  repaired,  when  it 
suddenly  reinfects  itself.  A  relapse  may  occur  a  second  or  even 
a  third  time. 

Complications  of  Chancroid. — Inflammations,  vegetations, 
phimosis,  paraphimosis,  lymphangitis,  erysipelas,  gangrene,  pha- 
gedena, simple  bubo,  and  virulent  bubo  may  complicate  chan- 
croid. 

Treatment. — Abortive.  All  the  stronger  mineral  and  some  of 
the  vegetable  acids,  and  caustic  alkalies,  prevent  the  development 
of  the  chancroid  if  apjjlied  over  the  inoculated  point  for  a  con- 
siderable time — about  two  hours — within  a  period  of  three  to 
twenty-four  hours  after  inoculation.  When  the  chancroid  is 
once  present,  active  caustics,  such  as  nitric  and  sulphuric  acids, 
and  the  actual  cautery  may  be  used.  Burn  every  portion  of 
every  ulcer,  no  matter  what  its  size.  In  applying  nitric  acid  it 
is  well  to  use  a  rather  blunt  glass  rod.  The  ulcer  should  be 
thoroughly  cleaned  and  dried  with  blotting  paper  slips.  A  drop 
of  pure  carbolic  acid  applied  and  then  absorbed  out  with  blot- 
ting paper  makes  the  acid  application  less  painful.  Now  the 
nitric  acid  is  thoroughly  applied  and  left  on  until  a  white  rim  of 


112  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

dead  tissue  announces  that  the  base  of  the  ulcer  is  destroyed. 
JSTow  the  nitric  acid  is  dried  up  with  blotting  paper  slips  and  the 
surface  touched  with  liquor  potassae  to  neutralize  any  excess  of 
acid  there  may  be.  The  burned  surface  is  dressed  dry  with  a 
little  absorbent  cotton.  The  eschar  separates  in  a  few  days, 
leaving  a  healthy  ulcer  which  heals  under  a  dry  dressing.  In 
cauterizing  a  chancroid  under  a  tight  prepuce,  inflammatory  phi- 
mosis may  come  on  unless  the  patient  be  kept  at  rest  after  the 
cauterization.  In  using  the  actual  cautery,  the  point  should  be 
carried  down  into  every  portion  of  the  ulcer  until  a  black  dead 
eschar  of  the  whole  surface  is  produced.  Cold-water  dressing  is 
applied  afterward  and  anodyne  given  until  pain  has  ceased. 
Apply  a  strong  solution  of  cocaine  before  burning.  If  the  ulcer 
has  lasted  only  a  few  days,  one  thorough  cauterization  cures  it. 
If  the  ulcer  is  already  several  weeks  old,  it  will  in  many  instances 
get  well  as  quickly  under  iodoform,  calomel,  or  other  dressing  as 
it  will  by  being  cauterized.  Nitrate  of  silver  does  harm,  since 
its  caustic  action  does  not  extend  deep  enough,  and  superficial 
cauterization  always  makes  matters  worse.  It  is  well  to  remem- 
ber that  greasy  local  applications  to  chancroids  are  bad.  When 
it  is  not  advisable  to  use  caustics,  cover  the  entire  surface  with 
iodoform  powder.  Cleanliness  is  of  the  first  importance.  Dusting 
the  surface  with  calomel  and  bismuth  is  a  good  expedient 
(Keyes). 

PRESCRIPTIONS  FOR  CHANCROID. 

R     Iodoformi 31J. 

Sig. :     Dust  on  sore  and  cover  with  lint  clipped  in  glycerine. 

— Ringer. 

R     Bismulhi  subiodidi 3iv. 

Sig.:     Dust  on  sore  and  use  dry  dressings. 

R     Pulveris  acidi  salicylici 3ij. 

Sig.:     Dust  on  sore  and  cover  with  dry  dressing.  —Auglada.. 

CHILBLAINS. 

Are  local  inflammations  of  the  skin,  and  are  to  be  met  with 
in  subjects  of  a  feeble  circulation.  They  are  more  common  in 
the  young  and  in  women  than  in  men,  and  are  generally  seen  on 


CHILBLAINS CHLOROSIS.  113 

the  toes,  fingers,  nose  or  ears,  and  are  caused  by  any  sudden 
change  of  temperature,  or  any  sudden  application  of  cold  or 
warmth.  Chilblains  may  show  themselves  as  simple  congestions 
of  the  skin,  attended  with  tenderness  or  itching;  or  when  the 
inflammation  is  more  severe,  vesication,  or  when  a  broken  chil- 
blain occurs,  sloughing  and  ulceration.  Any  external  warmth 
or  anything  that  excites  the  circulation  in  the  part  is  apt  to  in- 
crease the  symptoms. 

Treatment. — General:  Tonics,  good  diet,  external  warmth 
and  exercise.  Local:  AVhen  the  chilblain  is  not  broken,  the 
local  appli cation  of  the  tincture  of  iodine,  of  camphor  liniment, 
of  soap  liniment  with  opium,  or  of  simple  spirit,  not  only  gives 
comfort,  but  hastens  the  cure  of  the  disease.  Turpentine  and 
carbolic  acid  are  most  highly  recommended.  When  the  parts  are 
broken,  vaseline,  and  boracic  acid  ointment  are  the  safest 
remedies. 

PRESCRIPTIONS  FOR  CHILBLAINS. 

R     Acidi  carbolici gr.  x. 

Cosmolini 

Olei  terebinthinas aa §j . — M. 

Sig. :     Apply  to  the  affected  part.  — Davidson. 

R     Linimenti  chloroformi 51J . 

Sig.:     Apply  to  part  with  gentle  friction.    (Early  stage). 

— Davidson. 

R     Tincturee  iodi 5J. 

Sig.:     Apply  to   parts  with  brush.     (When   swollen    or  granu- 
lated). — Davidson. 

CHLOROSIS. 

Is  an  anaemia  occurring  in  girls  about  the  period  of  puberty. 
The  term  chlorosis  relates  to  the  peculiar  tint  the  complexion 
assumes  in  this  disease,  and  in  common  language  is  called 
"green- sickness"  (Bartholow). 

Cause. — Chlorosis  is  regarded  by  some  as  a  neurosis,  the 
blood  changes  being  secondary  to  the  neurosis.  There  is  nearly 
always  some  functional  derangement  of  the  sexual  organs.  Self - 
pollution  is  claimed  as  an  exciting  cause  of  chlorosis.  The 
patient  is  usually  light,  fair,  full,  round,  but  white,  having  blue 


114  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

eyes,  soft  tissues  and  feeble  muscles.  Heredity  may  exist 
(Loomis). 

Symptoms. — The  patient  becomes  despondent  or  morose. 
The  countenance  assumes  a  peculiar  waxy,  yellow,  or  yellow  - 
green  pallor.  The  face  is  puffy,  the  eyes  are  surrounded  by 
deep,  blackish  circles,  and  the  mucous  membranes  are  pale. 
There  are  muscular  weakness,  dyspnoea,  and  fits  of  cardiac  palpita- 
tion are  commou.  The  appetite  is  capricious.  The  patient  will 
•eat  with  avidity  chalk,  slate  pencils,  ashes,  dirt,  or  strongly  acid 
and  spiced  food.  Cardialgia  is  a  common  symptom,  and  belch- 
ing of  gas.  There  may  be  nervousness,  dry  cough,  etc.  (Flint, 
Xoomis  and  Bartholow). 

Differential  Diagnosis. — Chlorosis  may  be  confounded  with 
simple  anaemia,  Bright's  and  cardiac  disease.  In  anaemia  emacia- 
tion is  marked;  in  chlorosis  there  is  no  loss  of  flesh.  The  pecu- 
liar greenish  color  and  the  mental  state,  the  age  and  sex  and 
uterine  derangement  will  distinguish  it.  The  examination  of  the 
urine  in  Bright1  s,  and  of  the  chest  in  cardiac  disease  will  decide 
the  question  (Loomis). 

Prognosis. — Its  duration  is  very  uncertain.  It  is  not  a  self- 
limited  disease,  and  manifests  no  tendency  to  spontaneous  cure. 
As  a  rule  the  prognosis  is  very  unfavorable,  on  account  of  com- 
plications such  as  phthisis,  valvular  endocarditis,  and  gastric 
ulcer  (Loomis). 

Treatment. — Patients  should  have  an  out-of-door  life  with 
cheerful  companions  and  surroundings.  The  combinations  of 
iron  with  a  mineral  acid  are  usually  effective.  According  to 
Bartholow  the  combination  of  iron  with  arsenic  is  best.  Strych- 
nia and  the  lacto-phosphate  of  lime  are  useful.  Rest,  forced 
feeding,  massage  and  faradization  are  advocated  by  Weir 
Mitchell. 

PRESCRIPTIONS  FOR  CHLOROSIS. 

R     Tincturte  ferri  muriatis giv. 

Acidi  phosphorici  diluti gvj. 

Spiritus  limonis 3ij. 

Syrupi q.  s.,  add svj. — M. 

Sig. :     A  dessertspoonful  in  water  after  meals.  — Goodell. 


CHLOROSIS CHOLERA  MORBUS.  115 

R      Hydrargyri  chloridi  corrosivi gr.  j-ij. 

Liquoris  arsenici  chloridi 3J. 

Tincturse  ferri  chloridi 3iv. 

Acidi  hydrochlorici  diluti ^iv. 

Syrupi giij. 

Aqua?  ad gvj . — M. 

Sig. :     A  dessertspoonful  in  a  wineglass  of  water  after  meals. 

— Smith. 

R     Quininae  sulphatis gr.  xx. 

Ferri  sulph.  exsiccat gr.  xL. 

Strychnia?  sulphatis gr.  ss. — M. 

Ft.  massa  et  in  pilulas  no.  xx.  div. 
Sig.:     One  pill  thrice  daily.  — Bartholow. 

CHOLERA  MORBUS. 

Called,  also,  cholera  nostras,  English  cholera,  and  sporadic 
cholera,  is  an  acute  catarrh  of  the  stomach  and  intestines,  of 
sudden  onset,  and  manifested  objectively  by  vomiting  and  purg- 
ing. 

Causes. — Cholera  morbus  almost  always  occurs  in  July  and 
August.  Sudden  checking  of  the  perspiration,  or  suddenly 
chilling  the  surface  of  the  body  by  external  cold,  or  iced  drinks, 
and  sudden  changes  in  the  temperature  after  a  heated  term  will 
produce  it.  Its  most  frequent  cause  is  undigested  food,  as  shell- 
fish, unripe  fruit,  cucumbers,  etc  (Loomis). 

Symptoms. — An  attack  usually  begins  at  night  by  vomiting 
and  purging.  The  matters  vomited  are,  first,  undigested  food, 
gastric  mucous  and  bile.  The  vomiting  is  projectile  in  character, 
and  there  is  temporary  relief  after  each  attack.  The  bitter  fluid 
leaves  a  burning  sensation  in  the  mouth  and  throat.  Thirst  is 
intense.  The  evacuations  from  the  bowels  are  watery  and  pro- 
fuse, and  have  a  mouse -like  odor.  In  some  cases  purging  alone 
is  present.  There  is  intestinal  colic.  In  all  severe  cases  there 
are  cramps  in  the  lower  extremities,  especially  in  the  calves  of 
the  legs  and  feet.  The  skin  is  cold,  and  covered  with  a  pro- 
fuse perspiration.  Sometimes  the  abdominal  muscles  are  knotted 
by  cramps  (Loomis). 

Prognosis. — Cholera  morbus  is  rarely  a  fatal  disease.  The 
duration  is  from  a  few  hours  to  two  days,  and  in  the  rare  cases 


116  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

of  secondary  fever,   to   two  weeks.     When  the  patient    passes 
into  the  stage  of  collapse,  there  is  always  danger  (Loomis). 

Treatment. — In  mild  cases  ice  may  be  given  to  check  the 
vomiting,  and  sinapisms  applied  to  the  epigastrium.  In  severe 
cases  give  morphine  hypodermically,  and  apply  dry  heat  to  the 
extrenieties.  From  two  to  five  drops  of  diluted  sulphuric  acidr 
or  the  same  dose  of  muriatic  acid  diluted,  and  the  same  quantity 
of  tincture  of  opium  should  be  given  from  every  half  hour  to 
every  two  hours,  in  a  sufficient  quantity  of  ice- water.  Carbolic 
acid  alone  or  in  mixture  with  bismuth,  is  an  efficient  means  for 
arresting  vomiting;  besides,  its  properties  as  an  anti-ferment,  it 
has  a  local  anaesthetic  action  on  the  terminal  filaments  of  the 
nerves  in  the  mucous  membrane.  One-twelfth  to  one-sixth  of  a 
grain  of  calomel  will  relieve  the  vomiting  and  purging.  Chloro- 
dyne  is  very  effective  (Bartholow). 

PRESCRIPTIONS  FOR  CHOLERA  MORBUS. 

R     Acidi  nitrosi oj- 

Tincturse  opii  gtt,  xL. 

Aqua?  camphora? §viij . — M. 

Sig. :     One-fourth  part  to  be  taken  every  three  or  four  hours. 

— Hope. 

R     Tinctura?  opii 

Tinctura?  capsici 

Tincturse  rhei  aromatici 

Spiritus  mentha?  piperita? 

Spiritus  camphorae aa §iss. — M. 

Sig.:     Twenty  to  forty  minims,  diluted.  — Ruschenberger. 

R     Strychnia?  sulphatis gr.  J. 

Acidi  sulphurici  diluti §ss. 

Morphinse  sulphatis gr.  ij. 

Aquae  camphorse q.  s.,  ad giv. — M. 

Sig.:     A  teaspoonful  every  hour  or  two  well  diluted.     (In  threat- 
ened collapse.)  — Bartholow. 

CHOLERA  INFANTUM. 

Called  also  "summer  complaint;"  is  an  acute  gastrointes- 
tinal catarrh,  occurring  in  children  during  the  period  of  the  first 
dentition,  and  characterized  by  vomiting,  purging  and  fever 
(Bartholow). 


CHOLERA    INFANTUM.  117 

Causes. — Early  life — the  first  two  years — is  the  period  for 
•cholera  infantum.  Bad  hygiene  is  the  great  factor,  including 
clamp,  ill -ventilated  and  confined  houses,  continuous  high  tem- 
perature, and  improper  food.  Feeding  infants  the  coarse  food 
of  adults,  containing  much  starch,  and  artificially  fed  chil- 
dren, are  most  fruitful  causes.  It  prevails  more  in  cities  than  in 
the  country  (Bartholow). 

Symptoms. — It  begins  either  with  vomiting-  or  diarrhoea  or 
both.  The  child  rejects  all  food,  and  becomes  peevish.  Purging 
is  always  present,  and  the  passages  are  watery  and  greenish  in 
color,  and  contain  curdy  masses  mixed  with  mucus.  The  dis- 
charges are  more  or  less  slimy,  sometimes  frothy,  and  at  first 
have  a  distinctly  sourish  odor.  The  child  is  constantly  thirsty, 
and  becomes  stupid.  The  temperature  is  rarely  above  the 
normal.  The  number  of  passages  varies  from  six  to  seventy- five 
in  twenty-four  hours.  The  abdomen  at  first  may  be  distended, 
but  later  it  is  retracted  and  always  tender.  The  disease  usually 
lasts  a  week  (Loomis). 

Prognosis. — In  severe  cases,  unfavorable. 

Treatment. — In  the  treatment,  fresh  air  is  very  important. 
Fresh  cow's  milk  with  barley  and  lime-water  added  is  the  best 
artificial  diet ;  but  a  good  wet  nurse  is  always  to  be  preferred. 
To  relieve  the  intense  thirst,  the  child  may  suck  pounded  ice  in 
a  linen  bag.  The  only  drug  that  Loomis  has  found  efficacious 
in  controlling  the  vomiting  is  calomel,  which  should  be  given 
dry  on  the  tongue  in  minute  doses,  iV  of  a  grain  every  half  hour. 
Bismuth  and  carbolic  acid  are  very  useful ;  and  salicylic  acid  is 
also  of  value  in  arresting  fermentation.  For  the  diarrhoea,  give 
five  or  ten  drops  of  the  camphorated  tincture  of  opium,  every 
two  hours.  Camphor  and  brandy  may  be  given  for  the  purging. 
The  vegetable  astringents,  such  as  hsematoxylon,  kino,  and 
catechu  are  of  service  in  controlling  the  diarrhoea.  Flannels 
should  be  worn  next  the  surface  during  convalescence  (Loomis). 
According  to  Bartholow,  a  most  efficient  prescription  is  the  com- 
bination of  bismuth  and  carbolic  acid — ten  grains  of  the  former 
and  one-fourth  to  one-half  grain  of  the  latter,  every  two  hours. 


118  a  coxpexditjm  of  practical    medicine. 

PRESCRIPTIONS  FOR  CHOLERA  INFANTUM. 

R     Hydrargyri  chloridi  mitis  ...gr.  iij. 

Cretae  praep  gr.  xxxvi. 

Plumbi  acetatis gr.  xij. 

Pulveris  ipecac gr.  iij. — M. 

In  chart,  no.  xii.  div. 
Sig. :     One  every  three  hours.  — Condil. 

R     Olei  ricini 5ij  • 

Pulveris  acacia = 

Sacohari  albi — aa 31J . 

Tincturae  opii ITlxxi. 

Aquae  cinnamomi — q.  s  ad.  §iv. — M. 

Sig. :     A  teaspoonful  every  two  or  three  hours.  — West. 

R      Hydrargyri  cum  cretae gr.  ij. 

Sacchari  lactis gr.  x. — M. 

In  pulv.  no.  xii.  div. 
Sig. :     A  powder  every  hour.  — Ringer. 

R      Potassii  bromidi 3ij. 

Syrupi  simplicis |ss. 

Aquae  menthae  piperita? giss. — M. 

Sig. :     A  teaspoonful  every  hour  or  two  (when  cerebral  conges- 
tion). ,  — Bartholow. 

R      Tincturae  opii   deodorat , gtt.  xvj. 

Spiritus  amnion,  aromat 3J. 

Bismuthi   subnitratis 31J. 

Syrupi  simplicis 3iv. 

Misturae  cretae giss. — M. 

Sig. :     Shake  well  and  give  a  teaspoonful  every  two  or  three  hours 
to  a  child  8  to  12  months  old.  — J.  Lewis  Smith. 

CHORDEE. 

Is  a  gonorrhoea!,  painful,  down- curved  erection. 

Causes. — AVhen  the  inflammation  is  severe,  and  has  extended 
from  the  raucous  membrane  into  the  delicate  meshes1  of  the 
erectile  tissue  of  the  corpus  spongiosum,  the  erections  are 
painful.  In  this  condition  the  corpus  spongiosum  does  not  allow 
complete  distention  of  its  areola?,  and  hence  the  urethra  is  com- 
paratively too  short  for  the  erect  corpora  cavernosa  and  bends 
the  penis  downward  like  a  bow  during  erection.     If  the  corpora 


CHORDEE.  119 

cavernosa  should  become  inflamed  and  the  corpus  spongiosum 
escape,  the  arching  would  be  in  the  opposite  direction. 

In  chordee,  great  pain  is  felt  from  the  stretching  of  the  in- 
flamed erectile  tissue.  This  pain  is  measurably  relieved  by 
bending  the  penis  so  as  to  increase  the  bow.  Chordee  is  most 
frequent  during  the  night  and  toward  morning. 

The  pernicious  practice  of  "  breaking  the  chordee,"  which 
consists  in  roughly  straightening  the  penis  when  erect,  gives  rise 
to  a  haemorrhage  which  may  become  excessive,  and  be  the  start- 
ing point  of  organic  stricture. 

Treatment. — The  best  course  is  for  the  patient  to  keep  his 
urine  dilute  and  alkaline,  avoid  lascivious  thoughts,  and  resort 
to  prolonged  immersions  of  the  penis  in  very  hot  water  before 
retiring.  He  should  sleep  lightly  covered,  on  his  side,  on  a  hard 
bed,  after  a  small  evening  meal,  in  a  cool  room.  Bromide  of 
potassium,  in  doses  of  from  thirty  to  sixty  grains  at  night  in 
water,  repeated  once  if  necessary,  will  control  chordee  in  some 
cases.  In  other  cases  morphine  is  the  best.  When  a  patient 
wakes  with  chordee,  the  penis  should  be  plunged  into  the  coldest 
water  which  is  at  hand,  or  what  is  better,  if  it  is  winter,  laid 
along  a  piece  of  iron,  or  other  metal  which  has  been  exposed  to 
the  cold.  Lupulin  in  doses  of  from  thirty  to  sixty  grains  in 
powder  with  sugar,  is  of  undoubted  service  in  chordee. 

PRESCRIPTIONS  FOR  CHORDEE. 

R      Extracti  opii  aquos  gr.  iss. 

Olei  theobromse gr.  xxx. — M. 

Ft.  suppositor  no.  1. 
Sig.:     Introduce  into  the  rectum  on  retiring. 

— VanBuren  and  Keyes. 

R     Spiritus  camphoras sj 

Sig.:     One  teaspoonful  at  bed  time  in  water.  — Milton. 

R     Potassii  bromidi gr.  xv.-xx. 

Chloral  hydratis gr.  v. 

Spiritus  vini  gallici gij. 

Spiritus  camphoras 217.x. 

Aquae  menthee  piperita?  gj. — M. 

Sig.:     Give  at  bed  time.  — Milton. 


120  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

B      Extracti  opii  aquos gr.  ij. 

Pulveris  camphorse gr.  iv. — M. 

In  pil.  no.  ii.  div. 
Sig. :     One  or  both  on  retiring.  — VanBuren  and  Keyes. 

CHOREA. 

Called  also  St.  Vitus's  or  St.  Guy's  dance,  is  a  disease  of  the 
nervous  system,  which  is  characterized  by  irregular  and  invol- 
untary muscular  movements,  without  loss  of  consciousness 
(Smith). 

Age. — Chorea  may  occur  at  any  period  of  life,  but  a  large 
majority  of  the  cases  are  in  childhood.  The  maximum  frequency 
of  chorea  is  between  the  sixth  and  tenth  years. 

Causes. — All  writers  admit  that  there  is  often  an  inherited 
predisposition  to  chorea.  The  disease  usually  makes  its  appear- 
ance about  the  second  dentition,  or  at  puberty.  Rheumatism, 
intestinal  worms,  sexual  abuses,  amenorrhcea,  anaemia,  and  strong 
moral  emotions,  are  frequent  exciting  causes.  Fright,  shock, 
and  extreme  mental  labor  or  any  form  of  severe  nervous  disturb- 
ance may  act  as  an  exciting  cause.  It  may  be  produced  by  un- 
conscious imitation,  as  has  been  shown  in  schools.  Girls  are 
more  liable  to  it  than  boys.  Dysmenorrhcea  and  pregnancy  are 
causes  (Smith,  Flint,  and  Loomis). 

Symptoms. — Chorea  is  partial  or  general.  It  is  partial  when 
it  affects  a  few  muscles  or  groups  of  muscles;  general  when  all 
the  muscles  are  involved.  Speech  may  be  impaired  or  lost.  Loco- 
motion may  be  impossible.  The  movements  of  chorea  are  in- 
creased when  the  patient  is  conscious  of  being  observed,  and 
under  any  emotional  excitement,  and  are  usually  on  the  left  side. 
The  affection  is  not  accompanied  by  fever.  Anaemia  often  co- 
exists. Irritability  of  temper  is  a  notable  feature.  The  mental 
faculties  are  weakened.  The  affection  usually  comes  on  gradu- 
ally. Tenderness  of  the  spine  is  a  constant  symptom.  In  the 
severest  cases  sleep  is  disturbed.  The  duration  varies  from  a 
few  weeks  to  several  months;  the  average  is  between  two  and 
three  months  (Smith,  Flint  and  Loomis). 

Prognosis. — Complete  recovery  is  the  rule,  but  relapses  fre- 
quently occur. 


CHOREA COLIC.  121 

Treatment. — A  number  of  remedies  have  been  advocated  as 
affecting  a  cure  of  this  disease.  In  general,  when  different 
methods  of  treatment  of  any  disease  are  found  to  be  successful, 
it  is  a  fair  inference  that  the  disease  ends  favorably  from  an  in- 
trinsic tendency  (Flint).  If  there  be  rheumatism,  anaemia,  and 
constipation,  each  one  demands  its  appropriate  treatment. 
Fowler's  solution,  in  doses  of  three  or  four  drops  three  times 
daily,  is  very  efficacious.  Iron,  zinc,  strychnia,  opium  and  cannabis 
indica  are  useful.  The  application  of  the  ether  spray  to  the 
spine  for  four  or  five  minutes  at  a  time  daily  or  on  alternate 
clays  has  been  found  efficacious.  Children  with  chorea  should 
not  go  to  school.  Excellent  results  have  been  obtained  by  con- 
finement to  bed  in  a  darkened  and  quiet  room,  and  a  careful  but 
generous  diet  (Bartholow).  Morphine  and  chloral  may  be  given 
to  produce  sleep.  Galvanization  and  faradization  are  service- 
able. Cod-liver  oil  and  the  hypophosj^hates  are  useful  remedies. 
The  iodide  of  iron  is  good  in  some  cases  (Smith,  Flint,  and 
Bartholow). 

PRESCRIPTIONS  FOR  CHOREA. 

R     Chloral  hydratis gvj.-viij. 

Syrupi  aurantii  cort §iij. — M. 

Sig.:     A  teaspoonful  three  times  daily  for  one  or  two  months. 
(Child  ten  years  old.)  — Joffrey. 

R     Eserina?  snlphatis gr.  j. 

Aquae  d estill atae gvj . — M. 

Sig.:     Six  minims  hypoclermically  twice  daily,  with  tonics. 

— Riess. 

COLIC.     (Intestinal.) 

Includes  all  painful  affections  of  the  intestines  which  are 
not  caused  by  structural  changes  in  the  intestinal  wall  (Loomis),. 

Its  varieties  are  flatulent,  bilious,  lead,  copper,  gouty,  and 
rheumatic  colic.  It  is  a  purely  functional  affection,  and  is 
attended  by  irregular  spasmodic  contractions  of  the  muscular 
coat  of  the  intestine. 

Causes. — It  occurs  most  frequently  in  the  young.  Neurotic 
temperaments  and  a  sedentary  mode  of  life,  rheumatism,  chronic 


122  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

alcoholismus  and  gout  predispose  to  it.  Malaria,  syphilis  and 
liver  derangements  may  produce  it.  Cold  feet  is  often  its  excit- 
ing cause.  Direct  irritation  of  the  bowels  by  undigested  food, 
certain  articles  of  food,  as  cucumbers,  shell -fish,  strawberries, 
etc.,  will  cause  colic  in  some  persons.  Gaseous  collections  and 
distention  of  the  intestine  by  faeces,  or  by  bundles  of  worms, 
sometimes  excite  it.     Lead  and  copper  cause  colic  (Loomis). 

Symptoms. — The  attack  itself  comes  on  suddenly.  In  flatu- 
lent colic,  there  is  a  severe  twisting,  paroxysmal  pain  around  the 
umbilicus,  or  in  the  region  of  the  colon.  The  abdomen  becomes 
distended  with  the  flatus,  the  bowels  are  constipated,  eructations 
and  borborygmi  are  present,  and  there  may  be  vomiting.  Steady 
pressure  over  the  abdomen  relieves  the  pain.  There  is  no  rise 
of  temperature,  the  surface,  if  the  pain  is  severe,  is  cold  and  cov- 
ered with  clammy  perspiration.  On  palpation  during  a  spasm, 
the  intestine  at  points  may  be  felt  rigid  and  hard.  Flatulent 
colic  is  often  called  crapulous,  when  it  follows  a  too  hearty  meal, 
or  the  food  indigestible.  Crapulous  colic  is  accompanied  by 
pains  in  the  head  and  dimness  of  sight,  sometimes  by  uticaria 
and  roseola.  Flatulent  colic  is  most  frequently  met  with  in 
infants.  Bilious  colic  is  accompanied  by  nausea  and  vomiting, 
the  vomited  matters  being  greenish  and  yellow.  It  is  preceded 
by  nausea,  anorexia,  and  a  coated  tongue.  It  sometimes  begins 
with  a  chill.  The  bowels  are  obstinately  constipated.  Bilious 
colic  occurs  in  summer  and  autumn.  Lead  colic,  or  colica  pic- 
tonum,  comes  on  with  moderately  severe  paroxysms  of  pain. 
The  pain  is  located  about  the  umbilicus,  and  is  twisting  or 
grinding  in  character.  The  abdomen  is  contracted  and  hard; 
knots  of  rigid  intestine  can  sometimes  be  felt,  and  pressure 
somewhat  relieves  the  pain.  An  individual  suffering  from  lead 
poison  is  sallow,  anaemic,  and  often  the  extensors  of  the  forearm 
are  paralyzed,  and  along  the  edge  of  the  gums  is  a  deep  blue 
dotted  line  composed  of  lead. 

Prognosis. — Is  always  favorable. 

Treatment. — Will  depend  upon  the  cause.  Usually  purga- 
tives are  indicated.  In  all  forms  opium,  chloroform,  hydrate  of 
chloral  or  ether  may  be  given  to  relieve  the  pain  and  spasm.  In 
hysterical   and  nervous  subjects,  at   the   outset   of   the    attack, 


COLIC CONDYLOMATA.  123 

Hoffman's  anodyne,  asafoetida,  valerian  and  the  essential  oils 
often  quickly  relieve  the  pain  and  remove  the  flatus.  In  child- 
ren, bromide  of  potassium  in  carminative  waters  often  affords 
speedy  relief.  Gouty  colic  is  best  treated  with  oil  of  cajuput,  and 
carminatives.  The  feet  are  to  be  placed  in  a  mustard  bath,  and  a 
mustard  plaster  is  to  be  placed  on  the  abdomen.  In  lead  colic, 
opium  is  the  most  efficient  remedy.  It  will  often  relieve  the 
constipation.  A  milk  diet  acts  as  a  prophylactic  and  curative 
agent  (Loomis).  Twenty  drops  of  chloroform,  repeated,  if 
necessary,  at  short  intervals  will  sometimes  afford  prompt  relief 
in  severe  cases. 

PRESCRIPTIONS  FOR  COLIC. 

R      S}7rupi  rhei  aromatici 

Tincturae  opii  camphoratae 

Tincturae  cardamon  comp 

Aquae  cinnamomi aa §j. — -M. 

Sig. :     Two  to  four  teaspoonsful.     (For  crapulent  colic.) 

— Hartshorne. 

R      Magnesii   carbonatis  gr.  xl. 

Sacchari  albi giss. 

Tincturae  asafcetidae giss. 

Tincturae    opii 3ss. 

A  quae  §iss. — M. 

Sig.:     Five  to  sixty  drops,  according  to  age.     (In  infantile  colic.) 

— Dewees. 

R      S  piritus  cbloroformi 

Tincturae  cardamonii aa gij. — M. 

Sig.:     A  teaspoonful  every  half  hour  till  relieved.     — Bartholow. 

R      Tincturae  opii  deodorat gtt.  xii. 

Magnesii  calcinat err.  xii-xxiv. 

Sacchari  albi 3j . 

Aquae  anisi 3iss. — M. 

Sig.:     Shake  well.     One  teaspoonful  to  a  child  one  year  old. 

— J.  L.  Smith. 

CONDYLOMATA. 

Are  fleshy,  syphilitic  excrescences  about  the  anus  or  peden- 
d urn.  They  must  not  be  mistaken  for  warty  excrescences,  or 
vegetations,  which,  although  common  in  syphilitic  subjects,  have 
nothing  specific  about  them.     Vegetations  or  warty  growths  are 


124  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

liable  to  spring  up  around  syphilitic  chancre  of  the  prepuce  or 
anus,  as  they  are  with  chancroid,  balanitis,  gonorrhoea,  or  any 
irritation.  They  are  purely  accidental.  Syphilis,  as  a  poison, 
has  nothing  to  do  with  their  production.  Vegetations  upon  the 
penis  are  commonly  called  venereal  warts;  but  as  they  are  noth- 
ing more  than  papillary  overgrowths,  caused  by  irritating  fluids, 
or  simply  by  lack  of  cleanliness,  the  title  is  not  exact.  They 
are  not  influenced  like  condylomata,  by  anti- syphilitic  treatment, 
and  are  often  cured  by  mere  attention  to  cleanliness.  There  is  a 
contagious  element  about  warts  (Keyes).  In  children  they  seem 
to  come  froni  irritation  of  worms  (Bryant). 

PRESCRIPTIONS  FOR  CONDYLOMATA  AND  WARTS. 

JJr     Acidi  nitrici. SJ. 

Aquae 0.  j. — M. 

Sig. :     Use  frequently  as  a  wash.  — Ringer. 

|&     Acidi  chromici gr.  c. 

Aquae  destillatee Sj- — M. 

Sig.:     Apply  locally  with  match  or  glass  rod.  — Bartholow. 

JJr     Hydrargyri  chloridi  corrosivi gr.  x. 

Collodii  3v. — M. 

Sig  :     Paint  the  wart  once  daily.  — Kaposi. 

J&     Acidi  nitrici §ss. 

Sig.:     Apply  to  wart  with  match  three  or  four  times  a  week. 

CONJUNCTIVITIS. 

Is  an  inflammation  of  the  conjunctiva.  There  are  several 
varieties,  but  the  most  common  forms  which  the  general  prac- 
titioner will  meet,  are  hypersenria  palpebrals,  and  simple  or 
catarrhal  conjunctivitis. 

Causes. — Nasal  catarrh,  various  forms  of  eye-strain,  "hay 
fever"  or  "rose  cold."  Whatever  makes  vision  difficult  excites 
this  hyperaemia.  We  see  it  in  those  who  use  their  eyes  to  ex- 
cess; in  those  who  have  wept  extremely;  in  those  who  have 
errors  of  refraction,  and  in  those  who  work  in  dust.  The  causes 
of  simple  or  catarrhal  conjunctivitis  are  atmospheric,  ill-ventil- 
ated  rooms,   exposure   to  dust,  smoke   and  heat.     It  is  apt  to 


CONJUNCTIVITIS CONSTIPATION.  125 

occur  at  the  seaside  in  summer,  from  heat,  glare  and  dampness. 
Workers  at  the  forge,  millers,  cigar- makers  and  moulders  are  its 
special  subjects.  It  occurs  as  a  symptom  in  coryza,  measles, 
scarlatina,  variola  and  varicella  (Xoyes). 

Symptoms. — The  symptoms  are  worse  at  night  and  are 
aggravated  by  use  of  the  eyes.  There  is  heat,  and  burning  pain, 
with  pricking  and  itching  and  a  constant  sense  of  heaviness  and' 
of  sand  in  the  eyes  (  Xoyes  ). 

Treatment. — Ascertain  and  remove  the  cause.  Half  tea- 
spoonful  of  common  salt  to  a  pint  of  water,  and  a  teaspoonful  of 
"  Pond1s  extract"  to  a  tumbler  of  water,  are  applications  in  pop- 
ular use  (Xoyes).  Bathing  the  eyes  with  hot  or  cold  water  just 
before  bed-time  is  useful. 

PRESCRIPTIONS  FOR  CONJUNCTIVITIS. 

R     Sodii  biboratis  pulveris gj. 

Aquae  camphora? §vj. — M. 

Sig. :     Bathe  the  lids  and  drop  into  the  eyes  morning  and  even- 
ing. — Xoyes. 

R     Acidi  boriei gj. 

Aquas     5yj. — M.     Or 

R     Zinci  sulphatis gr.  ij. 

Aquas giv. — M.     Or 

R     Extracti  opii  fluidi gij. 

Aquae giv.  — M. 

Sig. :     Drop  into  the  eyes  morning  and  evening.  — Noyes. 

R     Argenti  nitratis gr.  ij.-v. 

Aquas  dtstillatae 5J. — M. 

Sig.:     Two  drops  in  the  eye  daily.     (In  granular  conjunctivitis.) 

— Xoyes. 

CONSTIPATION. 

Is  a  relative  term,  for  some  perfectly  healthy  persons  have 
only  one  movement  from  the  bowels  every  second  or  third  day, 
while  others  have  two  stools  daily.  Cases  are  recorded  where 
j:>eriods  of  three  months  have  elapsed  between  two  successive 
movements,  and  yet  the  individual  was  apparently  in  good  health 
(Loomis). 


126  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Causes. — In  those  accustomed  to  large  doses  of  opium  the 
bowels  have  been  known  to  move  only  four  times  in  a  year. 
Abuse  of  laxatives,  diseases  of  the  brain  and  spinal  cord,  liver, 
heart,  diabetes,  general  anaemia  and  chlorosis,  anxiety  and  pro- 
longed mental  labor  are  causes.  A  sedentary  life,  the  feeble, 
infirm,  the  bed-ridden,  child-bearing,  and  old  age,  are  predispos- 
ing causes.  Disregarding  the  calls  to  evacuate  the  bowels,  the 
use  of  food  leaving  no  residium,  deficiency  of  the  gastric  and  in- 
testinal juices,  impaired  muscular  contractility  and  loss  of  peris- 
taltic movements  are  causes  (Loomis). 

Symptoms. — The  patient  complains  of  sense  of  fullness  in 
the  rectum,  with  flatulence,  headache,  vertigo,  a  foul  breath  and 
anorexia.  Eruptions  such  as  psoriasis,  eczema,  prurigo,  ery- 
thema and  urticaria  often  appear  upon  the  surface.  There  are 
flushings  of  the  face,  dark  rings  around  the  eyes,  and  sometimes 
palpitation,  A  distended  colon  may  cause  pain  which  is  located 
either  in  the  chest,  bladder,  groin,  ovaries,  testicles,  loins  or  lower 
extremities  (Loomis). 

Treatment. — For  temporary  constipation  Epsom,  or  Rochelle 
salts  are  efficient.  For  habitual  constipation,  regular  hours  for 
the  evacuation  of  the  bowels,  articles  of  food  which  leave  a  bulky 
residue,  as  cracked  wheat,  oatmeal  and  fruits  which  have  fine 
seeds,  as  figs,  strawberries  and  prunes  sweetened  with  molasses 
are  sometimes  very  efficient.  A  goblet  of  hot  or  cold  water  just 
before  retiring  and  on  rising  will  often  be  of  service.  Daily 
exercise  in  walking  or  horseback  riding,  friction  and  kneading  of 
the  abdomen  and  the  galvanic,  and  faradic  currents  are  efficient 
means. 

PRESCRIPTIONS  FOR  CONSTIPATION. 

R      Extracti  cascarse  sagradse  fluidi... 

Elixir  simplicis aa £ij . — M. 

Sig. :     Two  teaspoonsful  at  bed  time.  — Bartholow. 

R      Extracti  nucis  vomicae  

Pulverus  piper,  nig ;aa .gr.  xx. 

Pil.  colocynth  comp gr.  1. — M. 

In  pil.  no.  xx.  div. 
Sig.:     One  every  night  or  second  night.  — Fothergill. 


CONVULSIONS.  127 

R      Pulveris  aloes  socot gr.  vij . 

Pulveris  rhei gr.  xxiv. 

Extracti  belladonna gr.  i. — M. 

In  pil.  no.  xii.  div. 
Sig. :     One  or  two  pills  as  required.  — DaCosta. 

CONVULSIONS. 

Spasm  is  sometimes  used  synonymously  with  convulsion;  but 
there  is  this  difference  :  the  word  spasm  is  used  when  we  wish  to 
express  the  idea  of  less  extensive  muscular  contraction;  and  con- 
vulsion, when  the  disorder  affects  the  muscles  of  the  whole  body. 
Spasms  may  be  clonic  or  tonic,  and  so  may  convulsions.  Convul- 
sions may  be  accompanied  by  a  loss  of  consciousness  and  sensi- 
bility, as  in  epilepsy  or  not  so  as  in  tetanus.  When  convulsions 
occur  in  children,  as  they  often  do  from  reflex  irritation  during 
teething,  from  disordered  digestion  or  from  poison  in  the  blood, 
they  are  then  called  infantile  convulsions.  Children  often  have 
convulsions  as  the  precursors  of  febrile  diseases.  Convulsions 
may  be  symptomatic  of  any  cerebral  disease  (Loomis). 

Treatment. — The  discovery  of  a  cause  will  indicate  the  treat- 
ment. Belladonna  and  the  bromides  may  be  used.  Hot  baths, 
counter-irritants  to  the  back  and  neck,  or  cold  to  the  head,  are 
often  of  service.  Chloroform  is  the  most  appropriate  agent  for 
controlling  the  spasms  temporarily  (Loomis). 

PRESCRIPTIONS  FOR  CONVULSIONS. 

R     Olei  ricini §j. 

Sig.:     A  teaspoonful  or  two  according  to  age.     (When  due  to  in- 
digestion.) — Witherstine. 

R     Athens  fort §iv. 

Sig. :     To  be  used  as  an  inhalation  until  paroxysm  is  broken. 

—J.  L   Smith. 

R     Misturse  asafcetidse §ij. 

Sig.:     A  tablespoonful  as  an  anema.  — Waring. 

R     Potassii  bromidi 3J. 

Aqua?  menthre  piperita? §ij. — M. 

Sig.:     A  teaspoonful  every  three  hours  for  a  day  or  two. 


128  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

CORYZA.     (See  Catarrh.) 
CROUP.     (Spasmodic.) 

Called  also  spasmodic  laryngitis  or  false  croup  in  contradis- 
tinction to  true  croup,  is  a  common  disease.  It  occurs  ordinarily 
between  the  ages  of  two  and  five  years. 

Causes. — In  some  families  there  is  an  hereditary  tendency. 
The  exciting  cause  in  most  cases  is  exposure  to  cold.  False 
croup  is  common  in  the  commencement  of  measles. 

Symptoms. — Spasmodic  croup  is  usually  preceded  for  a  day 
or  two  by  a  slight  cough  and  mild  nasal  catarrh.  It  commences 
in  most  patients  at  night  after  the  first  sleep  between  ten  and 
twelve  o'clock.  The  child  awakens  with  a  loud,  barking  cough. 
There  is  great  dyspnoea  due  to  swelling  and  tension  of  the  vocal 
cords.  The  face  is  flushed  and  expressive  of  suffering.  The 
child  cries.  The  skin  is  hot,  the  pulse  accelerated,  the  voice 
hoarse.  From  a  half  to  three  hours  these  symptoms  abate. 
Sometimes  the  attack  is  repeated  once  or  more  during  subsequent 
nights. 

Differential  Diagnosis. — Spasmodic  croup  may  be  mistaken  for 
true  croup.  The  friends  usually  make  this  mistake  before  the 
physician  arrives.  True  croup  begins  gradually.  The  cough 
becomes  more  harsh  and  the  respirations  more  difficult  by  degrees, 
by  day  as  well  as  by  night.  On  the  other  hand,  false  croup 
commences  abruptly  at  night  with  severe  symptoms  from  the 
first.  The  cough  in  false  croup  possesses  a  loud,  sonorous  char- 
acter, while  in  true  croup  it  is  harsh  and  less  full.  False  croup 
must  not  be  confounded  with  laryngismus  stridulous  or  internal 
convulsions.  The  latter  is  not  infiammatory,  but  purely  srmsmo- 
dic,  suddenly  commencing  and  abating  (Smith). 

Treatment. — To  relieve  the  spasmodic  action  of  the  laryngeal 
muscles,  a  warm  bath  should  be  employed  at  once,  and  the  pa- 
tient kept  in  ten  or  fifteen  minutes.  In  mild  cases,  a  warm  foot- 
bath may  be  sufficient.  An  emetic  should  be  given  at  the  same 
time  with  the  bath.  To  children  under  three  years,  syrup  of 
ipecac  should  be  given  in  doses  of  one  teaspoonful,  repeated  in 
twenty  minutes,  till  vomiting  occurs.     Children  over  the  age  of 


ckotp.  129 

three  years  are  best  treated  by  the  compound  syrup  of  squills  in 
teaspoonful  doses  till  vomiting  is  produced.  Eochelle  salts 
should  be  given  after  the  nausea  from  the  emetic  has  subsided. 
Inhalation  of  the  vapor  of  hot  water  and  a  sinapism  over  the 
neck  and  upper  part  of  the  sternum  are  useful  aids.  Spraying 
the  throat  with  a  solution  of  two  drachms  of  sodium  bicarbonate 
to  a  pint  of  lime-water  is  effective.  Five  or  six  drops  of  syrup 
of  ipecac,  or  of  compound  syrup  of  squills  should  be  given 
every  third  hour  the  next  day.  The  atmosphere  in  the  room  of 
the  patient  should  be  loaded  with  moisture.  Trosseau  applied 
a  sponge  soaked  in  water  as  hot  as  can  be  borne,  to  the  larynx, 
repeated  in  ten  minutes.  The  hoarseness,  dyspnoea,  and  cough 
diminish  with  this  treatment. 

PRESCRIPTIONS  FOR  SPASMODIC,  OR  CATARRHAL  CROUP. 

|&     Potassii  bromidi 

Chloral  hydratis aa gr.  xx. 

Syrupi  acacise §j . — M. 

Sig. :     A  teaspoonful  or  less,  according  to  age.  — Ellis, 

{&     Tincturse  aconiti  radicis gss. 

Sig. :  One  drop  in  a  teaspoonful  of  water  every  hour  till  urgent 
symptoms  abate;  then  every  two  or  three  hours.  — Ringer. 

JJr     Pulveris  aJuminis 31J. 

Syrupi  ipecac |j . — M. 

Sig. :  One  teaspoonful  every  twenty  minutes  until  vomiting  is 
produced.  A  hot  mustard  foot-bath  should  be  given  at  the  same 
time.  —J.  L.  Smith. 

Jfc     Syrupi  ipecacuanhas §ij. 

Sig. :  A  teaspoonful  every  fifteen  minutes  until  vomiting  is  pro- 
duced.    Then  five  or  ten  drops  every  three  hours  the  next  day. 

— Meigs  and  Pepper. 

CROUP.     (Membranous). 

Called  also  true  croup,  or  pseudo- membranous  laryngitis,  is 
a  common  and  fatal  disease,  and  occurs  most  frequently  between 
the  ages  of  two  and  twelve  years.  Some  authorities  regard 
membranous  croup  as  only  a  laryngeal  diphtheria. 

Causes. — According  to  J.  L.  Smith,  the  causes  of  croup  arc, 


130  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

diphtheria,  ''taking  cold,'1  measles,  pertussis,  scarlatina,  typhoid 
fever,  and  irritating;  inhalation. 

Symptoms. — Membranous  croup  commonly  begins  gradually 
and  insidiously,  revealed  at  first  to  the  physician  by  hoarseness 
or  huskiness  of  the  voice,  and  a  hoarse  or  harsh  cough.  Accord- 
ing  to  Bartholow,  it  is  a  purely  local  affection,  and  occupies  the 
larynx  exclusively.  The  exudation  is  on  and  not  in  the  mucous 
membrane,  and  blood-poisoning  never  results.  Occasionally 
masses  of  pseudo-membrane  are  expectorated.  The  dypsncea 
gradually  increases.  Whitish  or  grayish  patches  of  false  mem- 
brane may  be  seen  on  the  fauces. 

Prognosis. — It  is  one  of  the  most  fatal  diseases  of  childhood 
(Loomis). 

Treatment. — The  agents  which  have  been  most  employed  for 
the  purpose  of  dissolving  the  false  membrane  are  lime-water, 
lactic  acid,  pepsin  and  trypsin.  Smith  uses  the  following 
formula?  in  the  steam  atomizer  with  good  results  : 

R      Soclii  bicarbouatis gij. 

Aquae  calcis 0.  j. — M. 

Liquid  trypsin  may  be  employed  with  lime-water. 

R      Extracti  pancreatis  (Fairchilds)....3j. 

Sodii  bicarbonatis ^iij . — M. 

Add  one  teaspoonful   of  this   to  six  teaspoonsful  of  water,  and 
apply  ever}'  half  hour  with  a  camel's  hair  pencil. 

R      Liquor  potassae 3J. 

Aquae   calcis O.j. — M. 

This  may  be  inhaled  from  the  steam-atomizer. 

Calomel  has  been  used  with  good  results  in  doses  of  from 
five  to  ten  grains  in  the  commencement  of  the  disease. 

PRESCRIPTIONS  FOR  MEMBRANOUS  CROUP. 

R      Hydrargyri  sulphatis  flav. .......... gr.  ij-v. 

In  pulv.  no.  1. 
Sig. :     Use  as  an  emetic.  — Fordyce  Baker. 

R      Acidi  lactici ^iiiss. 

Aquse  destillata? §x. — M. 

Sig.:     Apply  with  atomizer  or  brush  frequently.  (To   dissolve 

the  membranes.)  — Mackenzie. 


CYSTITIS.  131 

CYSTITIS. 

Is  an  inflammation  of  the  mucous  membrane  limno*  the 
urinary  bladder.     It  is  acute  or  chronic. 

Causes. — Foreign  bodies,  especially  calculi,  in  the  bladder? 
blows,  protracted  retention  of  urine,  scarlet,  typhus,  and  typhoid 
fevers,  pyaemia,  septicaemia,  small -pox,  diphtheria,  myelitis? 
urethritis,  pyelitis,  and  pelvic  cellulitis  may  cause  cystitis.  Ureth- 
ral stricture,  paralysis  of  the  bladder,  gout  and  some  forms  of 
kidney  disease  are  accompanied  by  chronic  cystitis  (Loonrist. 

Symptoms. — Acute  cystitis  is  always  accompanied  by  fre- 
quent micturition,  only  a  few  drops  being  voided  at  each 
attempt.  After  its  passage  the  patient  strains  to  pass  more. 
There  are  dull  aching  pains  over  the  pubis;  sometimes  the  pains 
in  the  vesical  region  are  agonizing,  and  there  is  a  constant  burn- 
ing sensation  along  the  urethra.  The  urine  is  cloudy,  deposits 
mucus  on  standing,  is  alkaline,  and  sometimes  fetid.  Acute 
cystitis  lasts  about  one  week.  Chronic  cystitis  is  often  only 
indicated  by  a  frequent  desire  to  pass  urine.  Usually  there  is  a 
constant,  dull,  aching  pain,  or  a  sense  of  weakness  over  the 
bladder.  Only  a  small  quantity  of  urine  is  passed  with  each 
act  (Loomis). 

Treatment. — In  acute  cystitis,  the  patient  must  have  jjerfect 
rest.  Warm  hip-baths  give  relief.  Rectal  injections  of  opium 
and  belladonna  are  always  indicated,  with  large  poultices  and 
very  hot  fomentations  over  the  bladder.  The  bowels  should  be 
kept  free.  For  the  pain,  chloroclyne  is  the  best.  Twenty  minims 
of  liquor  potassse  in  mucilage  may  be  given  three  times  in 
twenty-four  hours.  In  chronic  cystitis,  the  catheter  is  to  be  reg- 
ularly and  persistently  used.  The  bladder  should  be  washed  out 
with  weak  solutions  of  borax.  Very  weak  solutions  of  salicylic 
acid,  carbolic  acid,  permanganate  of  potash,  and  chloride  of 
sodium  are  also  recommended.  The  daily  use  of  mineral  water, 
like  Vichy,  is  beneficial.  Drachm  doses  after  each  meal  of  the 
"Lafayette  mixture"  are  very  serviceable. 


132  A    COMPENDIUM    OF    PRACTICAL     MEDICIJNTE. 

PRESCRIPTIONS  FOR  CYSTITIS. 

R     Bals.  copab 

Spts.  etheris  nitros — aa 5ss. 

Liquor  potass* 5j  • 

Mucilag.  acacias ad  giv. — M. 

— "  Lafa}rette  Mixture.'' 
All  stimulating  drinks  are  forbidden  (Loomis). 

R     Atrophia?  sulphatis gr-j-    ■ 

Acidi  acetici gtt.  xx. 

Aicoholis 

Aquse — aa 3ss. — M. 

Sig. :     Four  drops  in  a  wineglassful  of  water  before  each  meal. 
(In  acute  cystitis.)  — Goodell. 

R     Extracti  tritici  fluidi 

Syrupi  amygdala? — aa  3ij- — M. 

Sig.:     A  dessertspoonful  in  water  five  or  six  times  daily.     (In 
chronic  cystitis.)  — Thompson. 

R     Potassii  citratis Sss. 

Spiritus  chloroformi oiiss. 

Tincturse  digitalis ZTCLxxx. 

Infusi  buchu o  viij . — M. 

Sig. :     Two  tablespoonsful  three  or  four  times  daily. — FothergilL 

CANCRUM  ORIS. 

Called  also  gangrene  of  the  mouth,  noma,  aqueous  cancer  of 
infants,  is  a  disease  of  childhood  occurring  between  two  and  six 
years.  The  point  of  attack,  which  is  most  frequently  the  inside 
of  the  cheek,  becomes  inflamed,  thickened  and  indurated,  then  a 
purple  hue  appears,  followed  by  sloughing  and  gangrene  (J.  L.. 
Smith). 

Causes. — This  is  a  very  rare  disease.  It  occurs  in  debilitated 
and  cachectic  children,  and  in  those  recovering  from  acute  dis- 
eases, such  as  scarlet  fever  (Loomis). 

Symptoms. — It  commences  with  pain  in  the  mouth,  an  ab- 
normal quantity  of  saliva,  and  offensive  breath.  Finally  an 
ulcer  appears,  with  a  dark,  ashy-brown  colored  slough.  It  may 
perforate  the  cheek. 

Prognosis. — Nineteen  out  of  twenty  die  (Loomis). 


CARDIALGIA CATALEPSY.  133 

Treatment. — Nitrate  of  silver,  and  even  strong  nitric  acid, 
should  be  applied  to  the  slough,  and  the  mouth  washed  with 
solutions  of  carbolic  acid  and  chlorate  of  potash.  The  best 
internal  remedies  are  quinine,  hydrochloric  acid  and  stimulants 
(Loomis). 

CARDIALGIA. 

Signifies  pain  at  the  cardiac  orifice  of  the  stomach  of  a  burn- 
ing character  and  shooting  into  the  chest,  and  up  the  oesophagus 
into  the  throat.  It  is  vulgarly  called  heartburn.  Everyone  has 
occasionally  experienced  this  symptom.  It  characterizes  certain 
cases  of  indigestion,  and  it  is  evidently  dependent  on  the  presence 
of  an  acid  in  the  stomach,  as  it  is  quickly  and  completely  re- 
lieved for  a  time  by  an  alkaline  remedy,  such  as  lime-water, 
liquor  potassse,  bicarbonate  of  soda  and  magnesia. 

CATALEPSY. 

Is  a  functional  disease  of  the  nervous  system,  closely  allied 
to  hysteria  and  epilej3sy.  It  is  characterized  by  loss  of  conscious- 
ness, sensation  and  volition,  accompanied  by  a  peculiar  muscular 
rigidity  in  which  the  limbs  remain  for  some  time  in  whatever 
position  they  are  placed  (Loomis). 

Causes. — Catalepsy  may  occur  at  any  age,  but  it  is  more 
common  in  females  about  the  age  of  puberty.  It  may  precede 
melancholia  and  epilepsy.  Traumatism,  strong  emotions,  fright, 
shock,  and  religious  excitement  may  induce  an  attack  (Loomis). 

Symptoms. — Catalepsy  occurs  in  paroxysms.  Consciousness 
is  suddenly  lost,  and  the  limbs  are  as  rigid  as  if  :petrified.  The 
face  has  a  death-like  appearance.  The  skin  is  cold  and  temper- 
ature is  sub-normal.  The  attack  may  last  a  few  minutes,  several 
hours,  or  for  days. 

Prognosis.— As  a  rule,  favorable  (Loomis). 

Treatment. — An  emetic  will  generally  cut  short  an  attack. 
The  faradic  current  may  be  employed  to  arouse  the  patient. 
Morphine  may  stop  the  paroxy&m,  given  hypodermically.  Asa- 
foetida,  valerian,  camphor  and  turpentine  may  be  given. 


134  A    C03IPEXDIU3I    OF    PRACTICAL     3IEDICIXE. 

CEPHALALGIA.     (See  Headache). 
CEREBRO=SPINAL  MENINGITIS. 

Called  also  spotted,  petechial  and  congestive  fever,  is  an  in- 
flammatory affection  of  the  arachnoid  and  pia  mater  of  both 
the  brain  and  spinal  cord. 

Causes. — Epidemics  have  occurred  at  all  seasons,  but  more 
often  in  cold  weather.  It  is  most  likely  to  attach  those  between 
ten  and  eighteen  years  of  age.  Cold,  damp  and  overcrowded 
houses  predispose  to  it.     The  real  cause  is  not  known  (Loomis). 

Symptoms. — In  some  cases  the  patient  is  suddenly  seized 
with  a  chill,  loss  of  consciousness,  becomes  comatose,  and  dies  in 
a  few  hours.  Headache  in  most  cases  is  prominent,  and  even  in 
a  condition  of  coma,  causes  the  patient  to  groan.  Pain  in  the 
back  and  upper  part  of  the  spine  is  a  characteristic  symptom  of 
the  disease.  Attempts  to  flex  the  head  on  the  chest  increase 
the  pain,  and  pressure  against  the  back  of  the  neck  often  induces 
excruciating  agony.  Soon  the  muscles  at  the  back  of  the  neck 
become  stiff,  and  the  head  extended  (opisthotonos).  Attempts 
to  swallow  are  painful.  The  temperature,  as  a  rule,  is  low.  The 
pulse  is  from  120  to  150.  The  pupils  are  often  unequal  in  size. 
The  face  is  pale  and  anxious,  and  has  a  dusky  hue.  Delirium 
comes  on.  The  pains  are  shooting  and  lancinating  in  character. 
The  eruption  is  usually  limited  to  the  face,  neck  and  lips;  it  is 
herpetic  in  character.     There  is  photophobia. 

Prognosis. — Unfavorable.     From  30  to  80  per  cent.  die. 

Treatment. — The  patient  should  be  put  to  bed  in  a  dark,  cOol, 
well- ventilated  room,  away  from  noise.  The  diet  should  be 
milk.  Opium,  bromide  of  potassium,  quinine,  and  ergot  in 
proj>er  doses  are  useful.  Cold  applications  to  the  head,  mustard 
foot-baths,  and  mustard  to  back  of  neck  are  serviceable. 

PRESCRIPTIONS  FOR  CEREBRO=SPINAL  MENINGITIS. 

R      Morphise  sulphatis gr.  ss. 

Acidi  sulphurici  aromat... 3j. 

Elixir  cinchona? ad gvj  — M. 

Sig. :     A  teaspoonful  every  two  hours  for  a  child  twelve  years  old. 

— Meigs  and  Pepper. 


CEEEBRO-SPIXAL    MENINGITIS — CIRCUMCISION.  135 

R      Acidi  hydrocyanici  diluti UT.  xx-xl. 

Sodii  bicarbonatis gi  iss. 

Syrupi  simplicis 

Aquse aa q.  s.,  ad siiss. — M. 

Sig. :     A  teaspoonful  every  three  or  four  hours  for  severe  vomit- 
ing. — Delafield. 

R      Hydrargyri  chloridi  mitis 

•    Pulveris  jalaps 

Sacchari  albi aa 3j. — M. 

In  pulv.  no.  x.  div. 
Sig.:     A  powder  every  hour  until  free  purgation  occurs. 

— Robert. 

CHICKEN=POX.     (See  Varicella.) 

CHIN=COUGH.     (See  Whooping-cough.) 

CIRCUMCISION. 

Was  instituted  as  a  religious  rite  by  Abraham,  about  2,000 
years  before  Christ. 

Several  Eastern  nations  still  practice  it  as  a  hygienic 
measure.  The  chosen  j>eople  preserve  the  custom  as  a  religious 
ceremony,  performing  it  on  the  eighth  day. 

Operation. — Mark  off  with  an  aniline  pencil  the  limits  of  the 
integument  which  it  is  proposed  to  remove.  This  line  should 
follow  the  curve  of  the  corona  glandis  at  a  short  distance  in  front 
of  it.  Now  seize  the  redundant  prepuce  with  the  forceps  so  that 
the  aniline  line  shall  lie  just  in  front  of  the  closed  blades,  taking 
care  not  to  include  the  glans  in  the  grasp  of  the  forceps.  With 
scissors  cut  off  the  outer  portion.  After  the  forceps  has  been 
removed,  the  inner  layer  of  the  prepuce  is  to  be  slit  down  to  the 
corona  upon  the  dorsum  of  the  glans  and  the  entire  mucous 
membrane  to  be  trimmed  away  on  either  side  up  to  the  frenum, 
leaving  only  enough  tissue  to  serve  to  hold  the  sutures.  Primary 
union  seems  always  to  occur.  In  the  infant  no  suture  is  re- 
quired. The  parts  coapt  naturally,  and  healing  is  accomplished 
usually  in  about  forty-eight  hours.  In  the  adult,  horse  hair  has 
proved  the  best  material  with  which  to  suture  the  cut  edge-. 
The  first  suture  should  be  applied  at  the  raphe.  The  ends  of  the 
suture  are  to  be  cut  off  about  an  inch  long,  to  prevent  the  wound 


136  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

from  rolling  in  during  the  swelling  of  the  first  two  clays.  It 
heals  in  from  fonr  to  eight  clays.  An  opiate  for  sleep  and  a  lax- 
ative are  the  only  medicines  usually  required  (Keyes). 

COMA. 

Is  complete  loss  of  consciousness,  and  there  is  the  appear- 
ance of  the  profoundest  sleep.  The  face  wears  a  confused  look ; 
the  pupils  are  sluggish,  often  dilated ;  the  mouth  is  open,  the 
tongue  dry.  Sensation  may  be  blunted,  but  is  not  destroyed ; 
nor  is  motion,  for  the  patient  moves  when  his  skin  is  pinched  or 
tickled.  Coma  always  betokens  a  serious  disturbance  of  the 
functions  of  the  brain  (DaCosta). 

Causes. — The  cranial  causes  are :  Hyperemia,  anaemia, 
ceclema,  compression,  tumors,  thrombosis,  embolism,  apoplexy, 
abscess,  softenings,  shock,  and  concussion.  The  most  thorough 
coma  is  seen  in  apoplexy;  it  comes  on  quickly,  and  is  attended 
with  a  noisy  respiration  and  a  slow  pulse.  The  extra  cranial 
causes  are :  Hysteria,  epilepsy,  uraemia,  cholseruia,  poisons  of 
drags,  narcotics  and  anaesthetics,  anti-spasmoclics,  alcohol,  poisons 
of  fevers,  malaria,  etc.  (Loomis). 

Treatment. — Discover  and  treat  the  canse. 

CORNS. 

Are  small  callous  thickenings  of  the  skin,  especially  on  the 
toes,  the  result  of  occasional  pressure.  Dr.  Sayre  writes  that  a 
corn  is  infinitely  more  painful  than  a  cancer,  and  is  capable  of 
inflicting  torment  and  agony  sufficient  to  destroy  the  sweetest 
disposition,  and  upset  the  best  regulated  families.  There  are 
two  varieties  of  corns,  the  hard  and  the  soft.  The  soft  corn  is 
found  between  the  toes,  is  exceedingly  tender,  and  is  liable  to 
become  inflamed.  The  hard  corn  has  a  hard,  white  core  in  the 
centre.  The  irritation  produced  by  pressure  upon  these  forma- 
tions may  give  rise  to  reflex  muscular  contractions  which  will 
draw  the  toes  up. 

Treatment. — Shoes  must  be  worn  which  will  permit  expan- 
sion of  the  foot.  Pare  the  corn  as  much  as  possible  without 
drawing  blood.     Then  rub  the  surface  with  solid  stick  of  nitrate 


COLD    FEET COUGH.  137 

of  silver,  and  in  a  few  days  another  layer  will  come  off.  Now 
surround  the  corn  with  narrow  strips  of  adhesive  plaster  to  pro- 
tect it  from  pressure.  To  the  soft  corn  apply  concentrated  nitric 
acid  or  the  solid  stick  of  nitrate  of  silver,  and  place  a  pledget  of 
cotton  between  the  toes.  In  a  few  days  the  hardened  mass  will 
come  away.  Glacial  acetic  acid,  and  carbolic  acid,  are  good 
applications.  According  to  Bartholow,  no  application  is  so  cer- 
tain, prompt  and  effective,  for  the  cure  of  corns,  as  liquor  potas- 
sse.  It  should  be  applied  by  means  of  a  glass  rod  to  the  summit 
of  the  corn  and  the  tissue  softened  by  it  scraped  off.  By  suc- 
cessive applications  the  callosity  is  removed  without  pain  or  dis- 
comfort. 

COLD  FEET. 

Many  persons,  especially  women,  are  troubled  with  cold 
feet,  particularly  at  night;  so  cold,  indeed,  as  to  effectually  pre- 
vent sleep  for  hours.  This  condition,  which  may  rank  as  a  dis- 
tinct ailment,  is  best  treated  by  immersing  the  feet  nightl}'  for  a 
few  minutes  in  cold  water,  rubbing  them  whilst  in  the  foot-bath 
diligently  until  they  become  warm  and  glowing,  and  then,  after 
thorough  drying,  clothing  them  in  thick,  over-large  woolen  or 
"fleecy  hosiery"  socks.  The  feet  may  be  sponged  first  with 
water  as  hot  as  can  be  borne,  and  then  for  a  few  seconds  with  a 
sponge  wrung  out  of  cold  water  (Ringer).  Dr.  Chapman  asserts 
that  the  ice-bag,  applied  along  the  lower  dorsal  and  lumbar  ver- 
tebrae, by  increasing  the  flow  of  blood  to  the  legs,  proves  very 
comfortable  to  jDersons  harassed  with  cold  feet;  and  he  has  often 
seen  the  feet  become  comfortably  warm  a  few  minutes  after  the 
application  of  ice.  According  to  Dr.  Anstie,  strychnia  promotes 
capillary  circulation,  and  he  recommends  it  in  troublesome  cold- 
ness of  the  feet  and  hands. 

COUGH. 

Is  a  sudden  and  violent  expiration,  having  usually  for  its 
object  the  expulsion  of  some  annoying  substance  from  the  air 
passages.  But  it  may  be  purely  nervous.  A  nervous  cough 
sometimes  occurs  in  children  and  in  chlorotic  girls.  The  cough 
is  usually  in  paroxysms,  has  a  peculiar  barking  tone  and  resem- 


138  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

bles  whooping  cough..  It  is  short,  painless,  and  without  expec- 
toration. 

Causes. — In  children,  it  may  result  from  diseases  of  the 
brain,  from  dentition,  from  worms,  and  spinal  irritation.  In 
others,  anaemia,  hysteria  and  nervous  excitement  may  be  the 
cause.  It  may  be  induced  by  involuntary  imitation.  A  school 
for  girls  was  suspended  on  account  of  the  large  number  of  cases 
(Flint  and  Smith). 

Treatment. — Tonic  remedies,  a  nutritious  diet,  out- door  life, 
cjuinia  and  small  doses  of  strychnia  are  useful.  No  remedy  is  so 
useful  in  ordinary  cases  as  iron.  Dr.  Cameron  used  the  follow- 
ing prescription : 

R     Ferri  subsulphatis §ss. 

Acidi  nitrici 3ss. 

Aquae  destillatse , , , , £ss. — M. 

Sig. :     Three  drops  four  times  daily  in  sweetened  water. 

R     Tincturse  belladonna? gtt.  xxxij. 

Potassii  bromidi 

Ammonii  bromidi — aa 3j. 

Syrupi  simplicis 5ij. — M. 

Sig.:     One  teaspoonful  three  times    daily.     (For  a  child  three 
years.)  — J.  L.  Smith. 

There  are  several  kinds  of  cough ;  according  to  the  amount 
of  expectoration,  a  cough  is  dry  or  moist ;  according  to  its  ori- 
gin, it  is  laryngeal,  tracheal,  bronchial,  sympathetic,  etc. 

A  dry  cough  is  indicative  of  irritation  either  in  the  larynx, 
trachea,  bronchi,  or  in  the  lung  substance.  An  elongated  uvula, 
pleurisy,  and  the  earlier  stages  of  phthisis  may  give  rise  to  a  dry 
cough.  But  the  irritation  may  not  be  situated  at  all  in  the 
respiratory  system.  Affections  of  the  liver,  stomach,  intestine, 
uterus  or  brain  will  occasion  an  obstinate  dry  cough.  Cough  is 
frequently  preceded  by  a  sensation  of  tickling  in  the  larynx. 
Lying  down  often  increases  its  intensity. 

PRESCRIPTIONS  FOR  COUGH. 

R     Misturse  asafoetida §iv. 

Ammonii  muriatis 3j. — M. 

Sig.:     A  tablespoonful  as  necessary.  (For  sympathetic  and  cough 
maintained  by  habit.)  — Bartholow. 


COUGH.  139 

R     Chloral  hydratis 

Camphora? — aa 3ss. — M. 

Triturate  in  a  mortar  till  a  clear  fluid  is  formed. 
Sig.:     Paint  with  a  camel's  hair  brush  over  the  larynx  to  allay 
spasmodic  cough.  — Bartholow. 

R     Extracti  gelsemii  fluidi giij. 

Sig. :  Three  to  five  drops  in  water  every  two  hours  until  droop- 
ing of  the  eyelids  and  dilation  of  the  pupil  takes  place.  (For  nervous, 
spasmodic,  reflex  and  irritative  cough.)  — Bartholow. 

R     Acidi  hydrocyanici  diluti sj. 

Tincturse  sanguinariaB giv. 

Syrupi  senegas gss. 

Syrupi  tolutan §ij. 

Aquas  lauro-cerasi  3vij  — M. 

Sig. :  One  or  two  teaspoonsful,  according  to  age,  every  three  or 
four  hours.     (For  irritable,  nervous,  and  cough  by  habit.) 

— Bartholow. 

Syrup  of  wild  cherry  and  syrup  of  lactucarium  are  excellent 
vehicles  for  cough  mixtures. 

R      Aluminis 33. 

Aquee gvj. — M. 

Sig.:  Use  in  the  form  of  a  spray  for  chronic  coughs  and  hoarse- 
ness. — Ringer. 

R      Chloroformi 3j . 

Morphia  sulph gr.  iss. 

Glycerinse gij . — M. 

Sig.:     A  teaspoonful  when  cough  is  troublesome. 

R      Olei  morrhuse O.j. 

Sig. :  A  teaspoonful  three  times  daily,  tor  a  while,  then  increase 
to  tablespoonful.     (For  chronic  cough.) 

A  drop  of  pure  beech -wood  creosote  may  be  given  with  the 
cod-liver  oil. 

A  teaspoonful  of  glycerine  added  to  water  or  a  little  lemon  - 
juice,  is  often  useful  in  coughs,  even  the  cough  of  phthisis. 

This  dose,  taken  at  night,  often  lessens  morning  cough 
(Ringer). 

Glycerine  of  tannin  is  a  very  useful  application  to  the  throat 
when  chronically  inflamed  and  so  productive  of  cough,  which  is 
often  the  case  in  children. 


140  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

The  tincture  of  iodine  may  be  used  as  an  inhalation  in  the 
chronic  forms  of  phthisis  to  allay  the  troublesome  cough;  and.  as 
an  inhalation  for  children  with  hoarse,  hollow  cough,  accompanied 
by  hoarseness  and  wheezing  at  the  chest.  Use  as  follows  :  Pour 
twenty  to  thirty  drops  of  the  tincture  of  iodine  in  a  half  or  a 
pint  of  boiling  water;  then  direct  the  patient  to  put  his  face 
over  the  mouth  of  the  vessel  and  breathe  the  iodized  steam  for 
five  or  ten  minutes  night  and  morning  with  the  head  covered 
with  a  towel  to  prevent  escape  of  the  steam  (Ringer). 

According  to  Eummo  a  four  per  cent,  solution  of  iodoform 
in  spirits  of  turpentine,  used  as  an  inhalation  or  spray,  will 
diminish  the  cough  of  phthisis  and  chronic  bronchial  catarrh. 

According  to  Ringer,  in  the  obstinate  winter  cough  with 
difficult  breathing  and  wheezing,  the  wine  of  ipecac  applied  as  a 
spray  to  the  fauces  once  or  twice  daily  is  very  efficacious.  The 
wine  may  be  used  pure  or  diluted. 

COMEDONES.— (See   Acne.) 
CYSTS. 

Are  developed  in  many  ways :  some  are  possibly  new 
growths,  some  are  formed  in  an  accidental  way  by  simple  effu- 
sion of  fluid  into  connective  tissue,  and  others  are  produced  by  a 
dilatation  of  occluded  ducts,  or  natural  gland  orifices,  the  cysts 
enlarging  by  the  secretion  of  the  ducts  or  gland  contents.  Of 
these  the  mucous  cysts  of  the  mouth  and  vagina,  the  sebaceous 
cysts  of  the  skin,  and  the  milk  cysts  of  the  breasts  are  the  best 
examples  (Bryant). 

Varieties. — Serous  cysts,  mucous  cysts,  sebaceous  cysts,  oil 
cysts  and  dermoid  cysts. 

Serous  Cysts  are  most  commonly  found  connected  with  the 
kidney,  ovary,  thyroid  or  breast.  They  are  sometimes  seen  in 
the  neck.     They  contain  a  limpid,  watery  fluid,  and  are  painless. 

Treatment. — It  is  dangerous  to  tajD  or  extirpate  a  cervical 
cyst.     Let  it  alone. 

Mucous  Cysts  are  found  wherever  mucous  glands  exist,  and 
are  caused  by  some  obstruction  to  the  escape  of  the  gland  con- 
tents.    They  are  found  on  the  lips,  within  the   cheeks,  on  the 


CALCIFICATION CHLOASMA.  1-11 

tongue  and  gums,  and  beneath  the  tongue  when  they  are  called 
ran  iila.     They  contain  a  thick  ropy  fluid. 

Treatment. — They  ma}"  be  excised,  or  their  walls  cut  into. 

Sebaceous  Cysts  appear  as  congenital  and  acquired  tumors. 
Some  are  caused  by  obstruction  to  the  orifice  of  the  sebaceous 
glands.  The  congenital  sebaceous  cyst  is  deeply  placed,  and  is 
more  common  about  the  orbit  and  brow.  They  contain  a  whitish 
or  yellowish  liquid  secretion  and  sometimes  hair.  The  acquired 
sebaceous  cyst  may  be  found  on  an)'  part  of  the  body,  but  it  is 
more  common  on  the  head  and  face.  When  on  the  scalp,  they 
are  known  as  wens. 

Treatment. — The  only  correct  treatment  is  their  removal. 

Dermoid  Cysts  are  frequently  met  with  situated  deeply  be- 
neath the  skin  and  mnscle.  They  are  congenital,  filled  with 
sebaceous  matter,  and  often  contain  hair. 

Treatment. — They  should  be  dissected  out. 

Oil  Cysts  are  met  with  but  rarely,  and  are  probably  always 
dermoid. 

CALCIFICATION. 

Called,  also,  calcareous  degeneration,  or  cretefaction,  is  an 
infiltration  of  the  tissues  with  the  phosphate  and  carbonate  of 
lime.  Calcified  tissues  are  recognized  by  their  hard,  sometimes 
stony  consistence.  Tissues  which  have  undergone  fatty  degen- 
eration are  especially  prone  to  calcification.  In  the  vast  majority 
of  cases  of  calcification,  the  lime  is  deposited  in  tissue  previously 
<li>eased.  Of  great  practical  importance  is  the  calcification  of 
the  cardiac  valves  in  chronic  endocarditis,  and  of  the  internal 
and  middle  coats  of  the  arteries  in  old  age  (Flint).  Removing 
tumors  from  the  pelvic  or  abdominal  cavity,  when  the  tissues 
and  arteries  are  calcified,  gives  rise  to  troublesome  or  even  fatal 
hemorrhage. 

CHLOASMA. 

Is  a  diffuse  form  of  excessive  pigmentation.  It  is  most  fre- 
quently met  with  in  women  during  pregnancy,  and  also  in  un- 
married females  between  the  ages  of  thirty  and  tin-  cessation  of 
the  menses,  as  a  result  of  disordered  menstruation,  and  of  dis- 


142  A    COMPENDIUM    OF    PKACTICAL     MEDICIJSTE. 

eases  of  the  sexual  organs.  It  has  the  appearance  of  a  dirty 
yellow  or  brown  discoloration,  generally  implicating  the  face, 
and  often  extending  across  the  forehead  from  temple  to  temple, 
and  from  near  the  eye -brows  to  near  the  roots  of  the  hair. 

Treatment. — Careful  attention  must  be  paid  to  the  general 
health  and  sexual  organs.  The  local  treatment  is  most  import- 
ant. Some  local  applications,  such  as  mustard,  cantharides,  and 
croton  oil,  are  apt  to  be  succeeded  by  new  epidermis  which  is 
more  deeply  pigmented  than  that  which  it  has  replaced,  and  are, 
therefore,  to  be  avoided;  while  others,  such  as  perchloride  of 
mercury  solutions,  have  exactly  the  opposite  tendency.  We 
may  use  a  perchloride  of  mercury  solution  of  the  strength  of 
five  grains  in  an  ounce  of  alcohol  in  the  following  manner:  Place 
the  patient  in  bed  and  apply  compresses  dipped  in  the  above 
solution.  Moisten  the  compresses  from  time  to  time  with  the 
fluid  without  displacing  them.  The  compresses  are  removed  in 
four  hours,  when  the  skin  is  found  to  be  reddened  or  blistered. 
If  blistered,  let  out  the  fluid  and  dust  the  surface  with  starch 
powder. 

CRAMP. 

In  writers'  cramp,  the  flexor  muscles  of  the  thumb  and 
fingers  become  rigidly  contracted.  Pianists,  violinists,  printers, 
tailors,  etc.,  are  sometimes  similarly  affected.  In  the  treatment 
of  writers'  cramp  and  allied  affections,  discontinuance  of  acts 
which  occasion  the  spasm  is  essential.  Galvanism  is  most  useful. 
It  seems  to  be  a  central,  not  a  peripheral  affection.  Some  persons 
are  liable  to  suffer  much  from  cramp  of  the  muscles  of  the  leg 
or  feet,  occurring  especially  at  night.  Bardsley's  treatment  con- 
sists in  sleeping  on  an  inclined  plane,  the  bed  being  twelve 
inches  higher  at  the  head  than  at  the  foot.  Galvanism  is  very 
effective  in  these  cases  (Flint). 

Cramp  may  occur  in  any  muscle.  Occasionally  the  stomach 
is  the  seat  of  cramps,  and  causes  great  pain,  and  ejection  of  food. 
Galvanism  seems  to  be  more  effective  than  other  forms  of  treat- 
ment. 


CIRRHOSIS DEBILITY.  143 

CIRRHOSIS.     (Of  Liver.) 

Called  also  interstitial  hepatitis,  is  an  inflammation  of  the 
connective  tissue  of  the  liver.  It  has  been  named  sclerosis  of 
the  liver,  "Gin -drinkers"  liver,  "hob-nailed"  liver,  etc. 

Causes. — The  chief  cause  of  cirrhosis  is  the  intemperate  use 
of  alcohol.  When  it  is  taken  in  a  concentrated  form  without 
food,  it  acts  as  a  direct  irritant  to  the  hepatic  circulation.  If 
this  irritation  is  long  continued  cirrhosis  is  the  result.  Those  who 
take  alcohol  before  breakfast  as  well  as  through  the  day  are 
almost  certain  to  develop  cirrhosis  of  the  liver.  Those  who 
partake  freely  and  daily  of  highly  seasoned  food,  even  though 
they  may  not  use  alcohol,  are  also  liable  to  develop  cirrhosis. 
Syphilis,  gout  and  rheumatism  cause  it  (Loomis). 

Symptoms. — Dull  pain  and  tenderness  in  the  hepatic  region, 
dyspnoea,  apathy,  headache,  nausea  and  furred  tongue,  and  loss 
of  appetite,  esj^ecially  for  meats,  are  the  chief  symptoms.  There 
may  be  slight  jaundice.  Tympanites  as  well  as  intestinal  catarrh 
usually  precedes  ascites.  Before  the  ascites,  the  abdominal  veins, 
especially  of  the  right  side,  are  sometimes  enormously  distended. 
Ascites  is  sometimes  absent.  The  stools  in  cirrhosis  are  charac- 
teristic. They  are  clay- colored  in  the  centre;  surrounding  this 
there  is  a  dull  pinkish  ring,  and  around  this  a  slate  grey  ring 
tinged  with  mucus.  The  urine  is  scanty  and  very  dark  colored 
(Loomis). 

Prognosis. — Unfavorable. 

Treatment. — All  spirituous  liquors  must  be  abstained  from. 
Nitro- muriatic  acid  and  cod-liver  oil  are  useful.  Dilute  nitric 
acid  and  columbo  assist  stomach  digestion.  Creosote  and  sul- 
phite of  sodium  are  of  service,  when  acid  fermentation  is  a  dis- 
tressing symptom.  For  the  ascites  and  general  dropsy,  squills 
and  digitalis  are  effective;  but  when  they  fail,  tapping  must  be 
resorted  to  (Loomis). 

DEBILITY. 

Dr.  Anstie  highly  extolled  alcoholic  stimulants  in  the  debil- 
ity of  old  age,  especially  in  the  condition  of  sleeplessness,  at- 
tended often  with  slow  and  ineffectual  digestion  and  a  tendency 


144  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

to  stomach  cramps.  He  employs  a  generous  and  potent  wine 
containing  much  ether.  According  to  Ringer,  the  good  old- 
fashioned  remedy,  rum  or  brandy  and  milk  taken  before  break- 
fast, is  useful  in  phthisis  and  in  exhausting  diseases,  and  is  a 
good  prop  to  town -living  women  who  suffer  from  morning  ex- 
haustion. Arsenic  is  useful  for  the  swollen  feet  of  old  or  weakly 
persons ;  or  for  old  people  with  a  weakly  acting  heart  and  feeble 
circulation,  who  often  suffer  from  breathlessness  on  exertion. 
Cod-liver  oil  is  useful  in  chronic  degenerative  diseases  of  old 
age.  In  nervous  and  general  debility,  cod-liver  oil  and  the  hypo- 
phosphites  are  highly  useful.  Quinia  is  of  great  benefit  to  pale 
and  badly  fed  town  dwellers.  Sea  bathing  is  recommended  in 
chronic  illness  with  debility. 

PRESCRIPTIONS  FOR  GENERAL  AND  SENILE  DEBILITY. 

R     Tinctura?  ferri  cbloridi 

Syrupi  simplicis — aa  sj. 

Aqua?  cinnamomi §ij . — M. 

Sig. :     A  teaspoonful  three  times  daily.  — Charity  Hospital. 

R     Spiritus  chloroformi 5v. 

Acidi  hydrochlorici  dil giiss. 

Infusi  cinchona? §x  v. — M. 

Sig. :     Two  tablespoonsful  three  times  daily.  — Fothergill. 

R      Quinia?  sulphatis gr.  xxx. 

Acidi  sulphurici  diluti q.  s.,  ad.  ft.  sol. 

Aqua? §ij . 

Tinctura?  ferri  chloridi £ss. 

Spiritus  chloroformi 3yj . 

Glycerina?  §iv. — M. 

Sig. :     A  teaspoonful  three  times  daily.  — Loomis. 

DELIRIUM. 

This  is  a  wandering  of  the  mind,  the  patient  muttering 
incoherent  words.  It  is  more  common  in  the  young  and  nervous 
than  in  the  old.  The  delirium  may  be  quiet  or  active.  It  may 
be  brought  on  by  acute  diseases,  especially  fevers. 


DELIRIUM.  145 

DELIRIUM.     (Tremens.) 

Occurs  most  frequently  in  old  topers  after  a  severe  drinking 
bout,  or  it  follows  the  sudden  withdrawal  of  stimulants,  or  an 
attack  may  be  induced  by  some  strong  moral  emotion  or  excite- 
ment, or  by  an  accident  or  injury  (Loomis). 

Symptoms. — The  appetite  is  lost  and  even  the  drink  is 
rejected.  The  trembling  increases ;  the  manner  grows  excited 
and  irritable.  Insomnia  is  an  early  symptom.  Hallucinations 
and  illusions  come  on.  The  delirium  usually  begins  at  the 
moment  of  falling  asleep  or  in  awaking.  He  then  sees  frightful 
objects — goblins,  demons  and  monsters — but  fully  awake  they 
vanish.  This  preliminary  state  is  often  called  "the  horrors." 
As  the  case  progresses  the  hallucinations  become  constant.  The 
patient  sees  snakes  on  the  wall  and  bed,  and  endeavors  to  escape 
from  them.  He  may  be  noisy,  furious,  and  dangerous.  There 
may  be  illusions  of  smell  and  hearing.  Delirium  tremens  usu- 
ally lasts  about  two  weeks,  by  which  time  recovery  or  death 
will  have  taken  place  (Bartholow). 

Treatment. — Provide  suitable  aliment  for  the  patient  and  try 
to  procure  sound  sleep.  Milk  and  lime-water  may  be  given 
freely,  to  which  it  may  be  advisable  to  add  whiskey  or  brandy.. 
E^o'-noa;,  beef-iuice  and  other  animal  broths  should  be  well  for- 
titled  with  red-pepper.  For  securing  sleep,  one-fourth  of  a  grain 
of  morphine  and  fifteen  grains  of  chloral  may  be  given,  if  the 
heart  is  not  weak.  Bromide  of  potassium  in  full  doses  may  be 
given  for  "the  horrors.'1  Pilocarpine,  tincture  of  digitalis  in 
drachm  doses,  tincture  of  cannabis  indica,  and  chloroform  inter- 
nally may  be  used  with  advantage. 

PRESCRIPTIONS  FOR  DELIRIUM. 

JJr     Potassii  bromidi  

Sodii  bromidi aa gr.  xv. 

Chloral  bydratis gr.  x. 

Tincturae  zingiberis ITtx. 

Tincturse  capsici  ITTv. 

Spiritus  ammonii  aromat gj. 

Aquse q.  s.,  ad gij. — M. 

Sig. :     Dose,  3ij.  — Starr. 


146  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Jfc     Chloral  hydratis £ss. 

Syrupi  aurantii  corticis 

Aqua? aa gss. — M. 

Sig. :     To  be  taken  in  one  dose,  and  repeated  if  necessary. 

— Liebreich. 

{Jr     Potassii  bromidi §ss. 

Syrupi  simplicis 5j . 

Aquse  foeniculi q.  s.,  ad giij. — M. 

.Sig. :     Two  teaspoonfuls  every  two  hours  — Ringer. 

J$     Potassii  bromidi  3j. 

In  pulv.  no.  vii.  div. 
Sig.:     A  powder  dissolved  in  one-half  tumblerful  of  water  every 
four  to  six  hours      (In  "the  horrors.")  — Bartholow. 

DIABETES  INSIPIDUS. 

Called,  also,  polyuria,  hyperuresis,  and  polydipsia,  is  char- 
acterized by  extreme  thirst,  and  the  secretion  of  a  large  quantity 
of  colorless  urine,  of  low  specific  gravity,  free  from  sugar  and 
albumen  (Loomis). 

Causes. — Diabetes  insipidus  may  occur  at  any  age  and  in 
either  sex.  Disturbance  of  the  sympathetic  ganglia  causes  dila- 
tation of  the  capillary  vessels  of  the  kidney,  and  produces  dia- 
betes. Blows  on  the  head,  injuries  to  the  medulla  and  spinal 
cord,  and  violent  emotions  have  all  apparently  caused  its 
development.  Drinking  large  quantities  of  ice -water  when  over- 
heated, and  exposure  to  cold  and  wet,  are  among  its  supposed 
causes  (Loomis).  Bartholow  gives  syphiloma  of  the  brain  as 
the  most  usual  cause. 

Symptoms. — Its  chief  symptom  is  the  passage  of  a  large 
quantity  of  limpid  urine;  the  quantity  varies  from  thirty  to 
sixty  pints  per  day.  Its  specific  gravity  ranges  from  1003  to 
1008;  it  is  remarkably  clear,  and  faintly  acid.  It  contains  no 
sugar  or  other  abnormal  ingredients.  There  is  intense  thirst. 
The  skin  becomes  harsh  and  dry;  and  the  temperature  sub- 
normal.    There  may  be  salivation  (Loomis). 

Prognosis. — Recovery  from  diabetes  insipidus  is  rare.  It 
may  last  many  years. 

Treatment. — At  all  times  the  body  should  be  warmly  clothed, 
and  the  skin  kept  active.     According  to  Bartholow,  the  iodides 


DIABETES.  147 

and  mercury  have  quickly  cured  cases  of  syphilitic  origin. 
Jaborandi  and  ergotin  have  been  successful.  A  course  of  iodide 
of  potassium  should  be  at  first  administered,  and  if  the  disease 
does  not  yield,  galvanism  should  be  tried. 

PRESCRIPTIONS  FOR  DIABETES  INSIPIDUS. 

Jfc     Extracti  ergotse  fluidi §ij. 

Sig. :     A  teaspoonful   three   times    daily,  increased   to   two   tea- 
spoonfuls.  — DaCosta. 

{&     Auri  chloridi 3j. 

Confect.  rosse gr.  xx. — M. 

Ft.  massa  et  in  pilulas  no.  xx.  div. 
Sig.:     A  pill  after  meals  thrice  daily.  — Bartholow. 

|$r     Pulv.  Valerianae  rad oii"lv- 

In  chart,  no.  xii.  div. 
Sig.:     A  powder  three  times  daily.  — Demange. 

DIABETES  MELLITUS. 

Called  also  glycosuria,  is  a  chronic  disease  characterized  by 
the  constant  presence  of  grape-sugar  in  the  urine,  by  an  increased 
urinary  discharge,  and  by  progressive  wasting  of  the  body.  It 
has  at  various  times  been  regarded  as  a  disease  of  the  kidney, 
alimentary  canal,  liver,  and  nervous  system,  but  its  exact  path- 
ogeny has  never  been  determined  (Loomis). 

Causes. — Diabetes  occurs  at  all  ages,  but  is  most  frequent  in 
middle  life.  It  appears  to  be  hereditary  in  some  cases.  Shock 
or  concussion  of  the  whole  body,  or  of  the  brain  and  spinal  cord, 
blows  upon  the  hepatic  and  renal  regions,  mental  shocks,  anxiety 
and  chagrin  may  cause  it  (Bartholow).  Pregnancy,  impaired 
digestion,  and  immoderate  use  of  sugar,  new  wine,  and  alcohol 
have  also  been  named  as  causes  (Loomis).  Excessive  activity  in 
the  glycogenic  function  of  the  liver  may  so  overload  the  blood 
with  sugar  as  to  cause  it  to  appear  in  the  urine  (Loomis). 

Symptoms. — Diabetes  may  be  acute  and  result  fatally  within 
two  or  three  weeks  from  the  time  the  increased  flow  of  urine  is 
noticed.  But  it  usually  comes  on  insidiously;  the  patient  notices 
for  some  time  that  he  has  been  passing  more  urine  than  usual, 


148  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

and  has  been  unusually  thirsty.  While  his  appetite  is  good,  yet 
he  is  losing  flesh  and  strength;  and  there  is  an  abnormal  dryness 
of  the  mouth,  throat  and  skin,  with  intolerable  itching,  followed 
by  desquamation.  There  is  loss  of  sexual  desire.  The  tongue 
is  red  or  coated ;  the  gums  are  pale,  retracted  and  bleed  easily, 
and  the  teeth  become  carious.  There  are  nausea  and  vomiting, 
with  constipation.  The  temperature,  pulse-rate  and  respirations 
are  below  the  normal.  In  some  cases,  there  will  be  little  thirst 
or  loss  of  appetite  and  no  emaciation  (Loomis). 

The  Urine. — Very  rarely  the  amount  of  urine  passed  is  but 
little  increased;  generally  it  rises  to  twenty  or  fifty  pints  in 
twenty-four  hours.  The  urine  is  acid,  of  a  light  straw  color, 
without  sediment.  The  specific  gravity  varies  from  1030  to  1070 
with  an  average  of  1040.  In  rare  cases  a  low  specific  gravity  of 
1008  or  1010  is  recorded  (Loomis). 

Prognosis. — The  disease  may  last  from  a  few  weeks  to  ten  or 
twelve  years.    Boils  and  carbuncles  may  complicate  it  (Loomis). 

Treatment. — Dieting  is  of  the  first  importance.  All  sacch- 
arine form  of  food,  or  any  article  that  can  be  converted  into 
sugar  should  be  avoided.  Hence,  starchy  foods,  bread,  arrow- 
root, tapioca,  sago,  such  vegetables  as  potatoes,  parsnips,  turnips, 
carrots,  beans  and  peas,  are  to  be  absolutely  avoided.  Salads, 
greens,  acids,  fruits,  all  kinds  of  flesh  and  fowl,  eggs,  cheese  and 
butter,  unsweetened  tea  and  coffee,  can  be  taken.  Baths  and 
moderate  exercise  should  be  taken.  Extract  of  opium,  morphia, 
and  codeia  in  small  doses  are  useful.  Mineral  waters  are  given. 
If  there  is  anaemia,  iron,  cod-liver  oil,  strychnia,  and  quinine 
should  be  given.  Surgical  operations  should  on  no  account  be 
undertaken  on  diabetic  patients. 

PRESCRIPTIONS  FOR  DIABETES  MELLITUS. 

R     Sodii  salicylates 3iv-vj. 

Glyceri  nee §j . 

Aquse ad §iij. — M. 

Sig..     Two  teaspoonfuls  three  times  daily.  — DaCosta.. 

R     Tincturse  opii 5j 

Tincturse  ferri  muriatis oix. — M. 

Sig.:     Twenty  drops  three  times  daily.  — Weller.. 


DIAEEIIGEA.  149 

R     Soclii  salicylatis .-5iij- 

Liquor  potassii  arsenitis 5j. 

Glycerinse oj- 

Aquas  cinnamomi ad Siij • — M. 

Sig. :     A  dessertspoonful  three  times  daily.  — J.  C.  Wilson. 

DIARRHEA. 

Is  the  frequent  discharge  of  fluid  or  semi-fluid  faeces.  It  may 
Ibe  acute  or  chronic. 

Varieties, — I.  Irritative  Diarrhoea  is  that  form  induced  by 
improper  and  unseasonable  food,  foul  water,  tainted  meats,  and 
drugs. 

II.  Symptomatic  Diarrhoea  is  a  part  of  the  natural  history 
of  typhoid  fever,  intestinal  ulcerations,  all  forms  of  cholera,  and 
other  diseases. 

III.  Mechanical  Diarrhoea  is  that  form  in  which  the  fasces 
are  made  fluid  by  a  large  amount  of  serum  poured  into  the 
intestinal  canal,  by  the  action  of  Epsom  and  Rochelle  salts. 

IV.  Nervous  Diarrhoea  may  be  caused  by  fright,  grief, 
great  anxiety,  and  severe  pain. 

V.  Vicarious  Diarrhoea  occurs  when  the  functions  of  the 
skin,  kidneys  or  lungs  are  suppressed;  the  flux  from  the  bowels 
affords  relief.  Chilling  the  body  suddenly,  or  intense  heat,  brings 
on  a  vicarious  flux. 

VI.  Fatty  Diarrhoea  is  the  result  of  faulty  pancreatic  di- 
gestion. 

VII.  Colliquative  Diarrhoea  is  a  copious  flux  occurring  in 
wasting  diseases  toward  their  close,  e.  g.,  phthisis,  cancer  and 
Bright1  s  disease. 

VIII.  Chronic  Diarrhoea  is  always  associated  with  some 
form  of  chronic  organic  disease  as  chronic  enteritis,  intestinal 
ulcers,  syphilis,  malaria,  scurvy  and  phthisis  (Loomis). 

Prognosis. — Depends  on  the  cause.  In  fatty  diarrhoea  50 
per  cent  die. 

Treatment. — Depends  on  the  causes  which  produce  it.  If  it 
depends  on  undigested  food,  a  full  dose  of  castor  oil,  or  rhubarb 
and  soda  should  be  given.  The  diet  should  be  restricted  to  milk 
and  lime-water.     Camphor,   kino,  bismuth,   or   dilute   sulphuric 


150  A    COMPENDIUM    OF    PRACTICAL     MEDICIiSTE. 

acid  may  be  given.     If  there  is  griping,  opium  may  he  combined 
with  the  bismuth  and  camphor. 

In  the  treatment  of  chronic  diarrhoea,  bismuth  is  the  most 
reliable  drug  (Loomis). 

PRESCRIPTIONS  FOR  DIARRHEA. 

Jfc     Spiritus  lavandulse  comp Sij. 

Tincturse  opii 31J . 

Tincturse  rhei gss. 

Olei  sassafras gtt.  x. — M. 

Sig. :     A  teaspoonful  after  each  meal.  — Loomis. 

J£     Olei  ricini ^ij. 

Pulveris  acacia? — 

Pulveris  sacchari aa ^ij. 

Tincturse  opii ITT.xxi. 

A  quae  cinnamomi ad giv. — M. 

Sig. :     A  teaspoonful  every  three  or  four  hours.     (For  children.) 

—West. 

{fc     Magnesii  sulphatis 

Tincturse  rhei 

Syrupi  zingiberis aa 5j. 

Aqua?  carui oix. — M. 

Sig. :     A  teaspoonful  three  times  daily,  to  a  child  one  year  old. 

—West. 

Jfc     Tincturse  opii  deodoratse gtt.  xvi. 

Bismuthi  subnitratis 3ij- 

Syrupi  simplicis Sss. 

Misturse  cretse Siss. — M. 

Sig.:     Shake  well  and  give  teaspoonful  every  three  hours  to  a 
child  one  year  old.  — J.  L.  Smith. 

JJr     Pulveris   ipecac gr.  ss. 

Pulveris  rhei gr.  ij. 

Sodii  bicarbonatis...  gr.  xij. — M. 

In  pulv.  no.  xii.  div. 
Sig.:     One  powder  every  four  hours  to  an  infant  one  year  old. 
(In  indigestion  with  acidity.)  — J.  L.  Smith. 

Jfc     Cretse  prsep 5ij. 

Tincturae  catechu Sss. 

Tincturse  opii XH.lxxx. 

Aquse  cinnamomi ad 5 viij. — M. 

Sig.:     Two  tablespoonfuls  after  each  motion.  — Fothergill. 


DIPHTHERIA.  151 

DIPHTHERIA, 

Is  one  of  the  most  dreaded,  one  of  the  most  fatal,  and,  un- 
fortunately, one  of  the  most  common  maladies  of  childhood.  It 
is  an  acute,  specific,  contagious  disease,  beginning  by  an  infec- 
tion of  the  throat,  and  characterized  by  a  local  exudation, 
glandular  enlargements,  and  systemic  poisoning,  and  having  for  its 
sequelae  various  paralyses  (Barthelow). 

Causes. — Diphtheria  is  a  contagious  disease,  propagated  by 
a  specific  poison,  the  form  of  which  is  not  known.  It  may  pre- 
vail as  an  epidemic,  or  occur  sporadically.  Filth,  bad  sewerage 
and  drainage,  overcrowding,  and  a  general  bad  hygienic  condi- 
tion favor  the  development  and  spread  of  diphtheria.  It  is  first 
a  local,  then  a  constitutional  disease.  The  stage  of  incubation 
usually  varies  from  one  to  eight  days.  No  age  is  exempt,  but 
from  the  second  to  the  fifth  year  is  the  period  of  greatest  suscep- 
tibility. Previous  attacks  afford  no  immunity  against  subsequent 
ones  (Loomis). 

Symptoms. — Are  both  local  and  constitutional.  The  local 
symptoms  begin  with  a  sensation  of  dryness,  prickling  and  pain 
in  the  throat.  There  is  hyperamiia  of  the  fauces,  and  on  the 
palate  or  tonsils,  minute  grayish -white  patches  appear.  The 
false  membrane  is  sometimes  dark-red  or  even  black.  There 
may  be  swelling  of  the  glands  of  the  neck.  The  Eustachian 
tubes,  (esophagus,  posterior  nares,  larynx,  vagina,  and  rectum 
may  be  involved.  The  constitutional  symptoms  are  chill,  fever, 
pain  in  the  head  and  back,  nausea,  vomiting,  and  even  convul- 
sions. The  temperature  may  be  103°  or  104°  F.,  the  pulse  120 
to  130.  The  patient's  condition  grows  worse  each  day.  until 
about  the  end  of  one  week,  when  the  membrane  is  thrown  off. 
The  loss  of  tendon  reflex  often  occurs  as  early  as  the  first,  sec- 
ond or  third  day.  It  is  a  symptom  of  diagnostic  value.  Dr. 
McDonnell  made  the  following  statement:  "Knee-jerk  is  absent 
from  the  very  first  day  of  the  illness,  in  many  cases  of  diph- 
theria.'1 

Symptoms  which  indicate  danger:  1.  Diarrhoea  may  cause 
exhaustion.  2.  Nausea  and  vomiting  coming  on  late  in  the  dis- 
ease.    3.  Albuminuria,  and  coma  may  occur  as  a  result  of  the 


152  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

nephritis.  4.  An  irregular  and  intermittent  pulse  throughout 
the  entire  course  of  the  disease.  5.  If  the  temperature  falls  to 
the  normal,  or  below,  and  the  exudation  shows  no  sign  of  ex- 
foliating.    6.  Convulsions  occurring  late  in  the  disease. 

Sequelae. — After  the  exudation  disappears  and  convalescence 
is  apparently  established,  sequelae  may  develop,  which  may  con- 
tinue for  months,  and  even  years.  The  commonest  is  paralysis 
of  some  of  the  voluntary  muscles ;  the  muscles  most  frequently 
affected  are  those  of  the  soft  palate  and  pharynx.  There  is  diffi- 
culty in  swallowing  and  inability  to  articulate  clearly.  As  the 
pharyngeal  paralysis  is  disappearing — or  from  two  to  ten  days 
after — the  muscles  of  the  lower  or  upper  extremity  may  be  in- 
volved. Before  the  occurrence  of  the  paralysis  there  will  be  a 
sensation  of  coldness,  pricking,  crawling  and  numbness  in  the 
part  about  to  be  affected.  There  maybe  paralysis  of  any  muscle. 
Paralysis  of  the  heart  may  occur.  Diphtheritic  paralysis  is 
always  entirely  recovered  from.  These  paralyses  may  follow  the 
mildest  as  well  as  the  more  severe  cases.  In  mild  cases  its  dura- 
tion is  two  or  "three  weeks,  while  in  others  it  has  continued  one 
or  two  years.  Other  sequels  are  nephritis  and,  endocarditis 
(Loomis). 

Differential  Diagnosis. — The  diagnosis  of  diphtheria  rests  on 
the  presence  of  a  membranous  exudation.  Ordinary  sore  throat 
or  catarrhal  pharyngitis  is  sometimes  confounded  with  diphtheria. 
Membranous  croup  is  a  local  affection,  while  diphtheria  is  a  con- 
stitutional disease.  Croup  is  not  contagious  or  inoculable,  while 
diphtheria  is  markedly  so.  In  croup  the  exudation  is  on  the 
surface  of  the  mucous  membrane;  in  diphtheria  it  is  in  its  sub- 
stance as  well  as  on  its  surface.  The  submaxillary  glands  may 
be,  and  often  are,  enlarged  in  diphtheria,  but  never  in  croup. 
An  erythematous  eruption  sometimes  makes  its  appearance  on 
the  upper  part  of  the  chest  and  back  in  diphtheria  (Loomis). 

Prognosis. — Death  rate  is  from  twenty  to  fifty  per  cent. 
Duration  varies  from  three  to  fourteen  days.  Cases  that  are 
apparently  doing  well  sometimes  terminate  very  unexpectedly 
and  suddenly  by  paralysis  of  the  heart.  Complications  make 
the  prognosis  more  unfavorable.  Death  may  occur  from  diph- 
theritic blood-poisoning. 


DIPHTHERIA.  153 

Treatment. — The  patient  should  be  kept  in  bed,  and  the 
room  well  ventilated,  and  have  a  temperature  of  70  to  75  degrees. 
The  patient  should  be  kept  scrupulously  clean.  Hot  poultices 
should  be  applied  externally  to  the  throat ;  steam  inhalation 
should  be  constant  fiom  the  onset  of  the  disease,  until  the  exuda- 
tion has  disappeared  ;  iron  and  brandy  should  be  given  freely; 
and  the  diet  should  be  fluid,  milk  preferably  (Loomis).  Accord- 
ing to  Bartholow,  a  solution  of  lactic  acid — strong  enough  to 
taste  sour — frequently  applied  by  means  of  a  mop,  gives  excel- 
lent results.  He  also  recommends  highly  the  inhalation  of  the 
vapor,  as  it  arises  from  the  slacking  of  lime.  The  false  mem- 
brane may  be  dissolved  by  very  frequent  inhalations  of  atomized 
lime-water  and  lactic  acid.  Bartholow  gives  the  following  to 
prevent  systemic  infection: 

Jfc     Liquor  iodi  comp 3ij. 

Acidi  carbolici oj  — M. 

Sig. :     One-fourth   of  a  drop  to  two  drops  in  water  every  four 
hours.     Also,  moderate  doses  of  whiskey  or  brandy  for  the  same  pur- 
pose. 
He  also   recommends   iron,   quinine,  strychnine,  galvanism 
and  faradism  for  the  paralytic  affections  of  diphtheria.     As  a 
solvent  for  the  false  membrane,  Dr.  J.  L.  Smith  recommends  the 
following  : 

Jfc     Olei  eucalypti oij- 

Sodii  benzoat oj  • 

Sodii  bicarbonatis oij- 

Glycerines Sij • 

Aquas  calcis... 0.  j. — M. 

Sig.:  To  be  used  with  the  hand  atomizer  from  three  to  five 
minutes  every  half  hour,  or  with  the  steam  atomizer  almost  con- 
stantly. 

PRESCRIPTIONS  FOR  DIPHTHERIA. 

{&     Papayotin    5j. 

Aquas 5iv. 

Glycerinas 5  viij . — M. 

Sig.:     Apply  locally  to  membrane.  — Jacobi. 

fy    Trypsin gr.  xxx. 

Sodii  bicarbonatis gr.  x. 

Aquse  destillatse 5j. — M. 

Sig. :     Apply  locally  to  membrane.  — Fernald. 


154  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

|Jr     Acidi  carbolici gtt.  x. 

Liq.  ferri  subsulph oiij- 

Gtycerinae 5j. — M. 

Sig. :     To  be  applied  every  three  to  six  hours  with  a  camel's  hair 
brush.  — J.  Lewis  Smith. 

JJ-     Tincturse  ferri  chloridi oii-iij- 

Potassii  chlorat 3j. 

Acidi  muriatic!  dil ...gtt.  x. 

Syrupi  simplicis oiv. — M. 

Sig.:     A  teaspoonful  every  hour  or  two.  — J.  Lewis  Smith. 

DIPSOMANIA. 

Is  a  term  commonly  applied  to  an  uncontrollable  desire  for 
alcoholic  drinks.  In  cases  of  dyspepsia  there  may  be  a  morbid 
craving  for  alcohol.  The  habitual  drunkard  feels  a  desire  for 
continued  indulgence,  and  lacks  moral  strength  enough  to  govern 
an  acquired  appetite  which  represents  a  morbid  condition.  Dip- 
somania is  to  be  treated  as  a  disease  of  body  and  mind.  The 
treatment  consists  in  withdrawing  the  patient  from  the  use  of 
alcohol  in  any  form,  and  in  the  employment  of  medicinal  and  hy- 
gienic measures.  This  morbid  craving  for  alcohol  is  the  sad 
inheritance  from  drunken  parents  (Flint).  According  to  Ringer, 
ten -minim  closes  of  tincture  of  capsicum  obviate  the  morning  vom- 
iting, remove  the  sinking  at  the  pit  of  the  stomach,  the  intense 
craving  for  stimulants,  and  promote  appetite  and  digestion  in 
dipsomaniacs. 

PRESCRIPTIONS  FOR  DIPSOMANIA, 

J$r     Tincturae  capsici IRx. 

Potassii  bromidi  gr.  x. 

Spiritus  ammonias 3j- — M. 

Sig.:     This  to  be  taken  at  one  dose,  and  repeated  several  times 
daily. 

Jfc     Tinctures  gentianae  comp 

Tincturae  columbas  comp...aa Sij- 

Tincturae  nucis  vomicae... ilt.Lxxx. — M. 

Sig. :     A  dessertspoonful  before  each  meal.  — Loomis. 


DIET-EATING DEOPSY.  155 

DIRT=EATING. 

Is  a  morbid  habit  which  heretofore  prevailed  to  a  consider- 
able extent  among  the  plantation  negroes  of  the  Southern  States. 
The  kind  of  earth  selected  is  loam  or  clay.  According  to  Dun- 
can, a  very  common  disease  among  negroes  on  plantations  is  a 
state  of  anaemia,  very  often  attributed  to  the  pernicious  habit  of 
dirt- eating.  Almost  every  large  j3lantation  has  three  or  four 
such  cases.  With  negroes,  dirt- eating  proceeds  from  the  same 
propensity  which  leads  white  females  to  resort  to  chalk,  mag- 
nesia, and  slate  pencils,  etc.,  in  order  to  relieve  a  disordered  acrid 
condition  of  the  stomach.     Discover  and  treat  the  cause  (Flint). 

DROPSY. 

Is  an  abnormal  collection  of  watery  fluid  in  the  areolar 
tissue,  or  in  the  serous  cavities  of  the  body.  Dropsy  is  not  a 
disease,  but  a  symptom.  It  is  associated  with  various  disorders. 
Dropsies  may  be  external  or  internal.  To  internal  dropsy  be- 
long hydrocephalus,  or  dropsy  of  the  brain,  hydrothorax,  or 
dropsy  of  the  chest,  and  ascites,  or  dropsy  of  the  abdomen.  Ex- 
ternal dropsies  are  illustrated  by  anasarca  and  oedema:  the  first 
is  a  universal  accumulation  of  serous  fluid  in  the  areolar  tissues; 
the  second,  a  localized  collection  in  the  same  tissue,  differing  in 
nothing  but  extent.  Both  exhibit  painless  swelling  of  the  sur- 
face, devoid  of  redness;  a  skin  often  stretched  and  shining, 
pitting  upon  pressure,  and  both,  if  punctured,  allow  a  watery 
fluid  to  run  out.  (Edema  is  most  commonly  perceived  around 
the  ankles.  Anasarca  is  usually  dependent  upon  disease  of  the 
kidneys,  or  of  the  heart.  The  swelling  ordinarily  begins  at  the 
feet  and  ankles  in  diseases  of  the  heart,  in  the  face  in  disease  of 
the  kidneys.  (Edema  may  be  due  to  the  same  causes,  or  the 
cause  may  be  purely  local,  as  when  we  see  oedema  happening  if 
a  bandage  be  applied  too  tightly,  or  if  swollen  glands  press 
upon  the  main  vein  of  a  limb.  We  see  oedema  in  venous  inflam- 
mation, in  milk-leg,  or  as  a  sequel  of  typhoid  fever,  in  conse- 
quence of  the  blocking  up  of  the  femoral  vein  by  coagulum.  In 
these  cases,  the  oedema  is  one-sided.     A  circumscribed  oedema, 


156  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

also    accompanies    erysipelas   of   the  .skin.     Another    source  of 
double-sided  oedema  is  anaemia  (DaCosta). 

Causes  of  General  Dropsy. — The  most  common  are  diseases  of 
the  heart,  of  the  kidneys,  or  of  the  liver.  Cardiac  dropsy  begins  in 
the  feet  and  ankles.  Renal  dropsy  is  usually  much  more  general 
than  cardiac,  and  does  not,  like  cardiac,  begin  in  the  most  de- 
pendent parts,  but  is  often  first  noticed  in  the  face  and  eye -lids. 
The  proof  that  dropsy  is  renal  is  furnished  by  the  presence  of 
albumin  and  casts  in  the  urine.  The  most  usual  kind  of  dropsy, 
dependent  upon  an  affection  of  the  liver,  is  abdominal  dropsy 
(DaCosta). 

Dropsies  may  be  divided  into  three  classes :  Inflammatory, 
mechanical,  and  cachetic  or  hydrsemic.  Inflammatory  dropsy  is 
due  to  a  moderate  degree  of  inflammatory  alteration  in  the  coats 
of  the  blood  vessels,  and  produces  collateral  oedema.  Of  this 
nature  are  cases  of  oedema  glottidis,  of  hydrocele,  and  of  hydro- 
cephalus. 

Mechanical  dropsy  is  the  result  of  some  obstruction  to  the 
current  of  blood  in  the  veins.  The  most  frequent  of  the 
mechanical  causes  of  general  dropsy  is  valvular  diseases  of  the 
heart. 

Hydraemic  or  cachectic  dropsy  is  the  result  of  an  impover- 
ished and  abnormally  watery  state  of  the  blood.  The  most 
important  cause  of  hydraenric  dropsy  is  Bright's  disease. 

PRESCRIPTIONS  FOR  DROPSY. 

J&     Spiritus  chloroformi HI  xx. 

Tinctune  digitalis ITC.x. 

Infusi  buchu Sj. — M. 

Sig. :     To  be  taken  three  or  four  times  daily,  and  followed  by  a 
good  drink  of  water.     (In  renal  dropsy.)  — Fothergill. 

Jfc     Infusi  digitalis si  v. 

Sig.:     A  tablespoonful  two  or  three  times  daily.        — Bartholow. 

J&     Potassii  bicarbonatis gr.  x. 

Ferri  et  amnion,  citrat  gr.  v. 

Tincturas  digitalis ITT  x. 

Infusi  buchu sj. — M. 

Sig.:     To  be  taken  three  times  daily.     (In   cardiac  dropsy  with 
gouty  tendency  or  debility.  — Fothergill. 


DYSENTERY.-  157 

DYSENTERY. 

Called  also  "  bloody  flux,"  is  an  ulcerative  colitis.  It  is  a 
disease  characterized  by  tormina,  tenesmus,  mucus,  and  mucus 
and  blood  stools,  burning  pain,  with  more  or  less  constitutional 
disturbance  (Bartholow).' 

Causes. — It  occurs  in  both  sexes  and  at  all  ages.  Sudden 
arrest  of  perspiration  by  exposure  to  cold  and  dampness  is  one 
of  the. most  common  causes.  It  occurs  in  late  summer  and 
autumn  and  in  warm  rather  than  in  a  cold  climate.  It  is  preva- 
lent in  malarious  regions.  Impure  air  and  water,  bad  or  insuffi- 
cient food  are  causes  (Bartholow). 

Symptoms. — In  the  epidemic  form,  dysentery  may  begin 
suddenly,  but  in  the  other  forms  it  conies  on  gradually.  There 
is  more  or  less  catarrh  of  the  intestines,  diarrhcea,  chilliness, 
fever,  and  a  feeling  of  malaise.  In  two  or  three  days,  pain  in 
the  descending  colon  is  felt.  It  is  described  by  the  term  tor- 
mina— "colicky  pains."  There  is  pain  of  a  burning  character  in 
the  rectum,  with  the  sense  of  the  presence  of  a  foreign  body,  and 
with  the  desire  to  strain  for  its  expulsion.  Nothing  comes  away 
but  mucus,  either  alone  or  tinged  with  blood.  The  tenesmus  con- 
tinues. There  may  be  ten  to  fifty  stools  daily.  The  patient 
becomes  weak  early.  His  skin  is  dry,  harsh  and  wrinkled,  his 
pulse  small,  quick  and  feeble.  The  discharges  emit  a  horribly 
fetid  odor.  In  the  severe  cases,  the  patient  passes  into  the  stage 
of  collapse,  the  jmlse  ceases  at  the  wrist,  hiccough  comes  on,  the 
skin  is  covered  with  a  cold  sweat,  the  hands  become  cold  and 
livid,  the  face  is  shrunken,  the  eyes  deeply  sunk,  and  the  voice 
husky.  In  mild  cases  convalescence  is  established  about  the 
eighth  day.  In  the  more  severe  cases,  the  duration  is  more  pro- 
tracted (BartholoAv). 

Prognosis. — Is  good  in  mild  cases,  but  in  severe  cases  bad. 

Treatment. — 1.  Food.  If  the  stomach  is  irritable,  milk,  with 
one-fourth  lime- water,  is  the  best  food.  If  the  digestion  remains 
good,  the  patient  can  take  milk,  eggs,  beef-juice,  ice-cream, 
boiled  custard,  oyster- soups,  mutton,  chicken  and  beef -broth. 
Where  there  is  much  depression  of  the  powers  of  life,  egg-nog 
may  be   freely  given.     2.  Medicine.     According  to   Bartholow,. 


158  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  sulphate  of  magnesia  in  solution  with  dilute  sulphuric  acid 
is  entitled  to  the  first  j3lace  as  a  remedy.  It  must  be  given  in 
laxative  doses,  early.  It  serves  a  triple  purpose :  it  empties  the 
canal  of  retained  faeces,  it  lessens  hyperemia  by  setting  up  an 
outward  diffusion ;  its  after  effect  is  astringent  and  sedative. 
Ipecac  is  an  excellent  remedy,  and  must  be  given  in  the  first 
stage,  before  the  mucous  membrane  is  stripped  off,  and  in  scruple 
to  drachm  doses,  every  four  to  six  hours.  The  first  doses  empty 
the  stomach,  and  the  following  ones  produce  copious  bilious 
evacuations,  called  "ipecac  stools.'1  The  utility  of  ipecac  ceases 
when  these  stools  are  produced.  It  is  best  given  in  milk  in 
twenty  grain  doses  with  aromatic  powder  added.  Castor- oil,  in 
purgative  doses,  in  the  first  stage  is  very  efficient.  After  the  first 
stage  is  passed,  an  emulsion  of  oil  (almond  oil)  and  turpentine 
combined  with  opium  is  very  serviceable.  When  destruction  of 
the  mucous  membrane  is  beginning,  the  most  effective  remedies 
are  corrosive  sublimate,  sulphate  of  copper,  sulphate  and  oxide 
of  zinc,  acetate  of  lead,  bismuth,  arsenic,  etc.  Of  this  list,  sul- 
phate of  copper  and  arsenic,  combined  with  opium,  are  most 
effective.  One  drop  of  Fowler's  solution  and  five  to  twenty 
drops  of  deodorized  tincture  of  opium,  every  three  hours,  gives 
excellent  results.  One-twentieth  of  a  grain  of  sulphate  of  copper 
with  one- eighth  of  a  grain  of  morphine  every  three  hours  is  good 
treatment  (Bartholow).  Bismuth  in  large  doses  (gr.  xxx.-xl.) 
every  four  hours  with  carbolic  acid  is  2-ood.  Excellent  results 
are  obtained  by  washing  out  the  bowels  with  warm  water.  Very 
great  relief  is  affected  by  the  injection  of  starch  and  laudanum. 
Eight  ounces  of  a  strong  solution  of  silver  nitrate  (gr.  xx.  to  the 
ounce),  thrown  into  the  sigmoid  flexure,  is  effective.  Morphine 
hypodermically  is  effective. 

External  Applications. — The  cold,  wet  jDack,  the  ice-bag,  but 
generally  hot  applications  afford  more  relief.  The  turpentine 
stupe  is  useful.  If  collapse  comes  on,  active  stimulation  is  neces- 
sary. 


DYSE^TEEY DYSMEISTOREHCEA.  159 

PRESCRIPTIONS  FOR  DYSENTERY. 

Jfc-     Tinctura?  opii  deodorat 3ss. 

Bismuth  subnitrat 3ij. 

Aquse  mentbse  pip 

S yrupi  zingiberis — aa §j . — M. 

Sig. :     Shake   bottle.     Give    one   teaspoonful    every  two   to  four 
hours,  to  a  child  five  years  old.     Half  dose  for  a  child  one  year  old. 

— Smith. 

J£     Vini  ipecac §ss. 

Sig. :     One  drop  every  hour.     (In  acute  or  chronic  form  of  chil- 
dren, with  slimy  stools.)  — Ringer. 

{$r     Piumbi  acetat gr.  xxiv. 

Pulv.  ipecac gr.  iij. 

Pulv.  opii gr.  iij. — M. 

Ft.  massa  et  in  pil.  no.  xii.  div. 
Sig. :     One  pill  every  two  hours  until  blood  ceases,  then  at  longer 
intervals.  — DaCosta. 

Jfc     Hydrargyri  chloridi  mitis..., 3j. 

In  pulv.  no.  vii.  div. 
Sig.:     A  powder  two  or  three  times  daily.     (In  epidemic  form.) 

—Hull. 

Jfr     Cupri  sulphatis gr.  ss. 

Magnesii  sulphatis sj . 

Acidi  sulphurici  dil 3j. 

Aqua? §iv. — M. 

Sig. :     A  tablespoonful  every  four  hours.     (In  acute  form.) 

— Bartholow. 

DYSMENORRHCEA. 

Is  painful  menstruation.  At  the  menstrual  period  women 
normally  feel  unwell,  have  a  few  vague  pains  in  the  loins,  and 
an  irritable  temper. 

Varieties  and  Causes. — 1.  Neuralgic  or  sympathetic  dysrnen- 
orrhoea  is  seen  in  nervous  or  hysterical  women,  and  is  accom- 
panied by  neuralgia  in  other  localities.  2.  Congestive  or  inflam- 
matory dysmenorrhea  occurs  where  there  is  excessive  congestion 
of  the  uterus  and  ovaries  from  any  cause.  3.  Mechanical  or 
obstructive  dysrnenorrhcea  is  due  to  some  cause  which  mechani- 
cally obstructs  the  outflow  of  blood,  as  stenosis  of  the  os  uteri, 


160  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

or  sharp  flexions.  4.  Membranous  dysmenorrhea  is  sometimes 
associated  with  endometritis.     5.  Ovarian  (Pozzi). 

Symptoms. — Pain  occurs  preceding,  during,  or  following  the 
menstrual  flow.  In  the  mechanical,  the  pain  occurs  with  the 
appearance  of  the  flow,  and  consists  of  a  series  of  uterine  cramps 
due  to  the  effort  of  the  uterus  to  expel  blood  clots  from  its  in- 
terior. In  the  congestive,  the  pain  precedes  the  flow,  and  is  re- 
lieved when  the  latter  becomes  free.  In  the  neuralgic,  the  pain 
is  referred  to  the  hypogastrium,  left  ovarian,  and  intercostal 
regions.  It  often  occurs  in  the  intermenstrual  period,  but  is 
always  aggravated  at  the  time  of  the  sickness.  In  the  membran- 
ous, the  pain  lasts  throughout  the  period,  and  until  the  expulsion 
from  the  uterus  of  the  more  or  less  complete  membranous  cast. 

Treatment.. — In  the  mechanical  or  obstructive,  dilate  the  sten- 
osis, correct  the  flexion,  and  prevent  its  recurrence.  In  the  con- 
gestive, give  saline  laxatives,  hot  foot-  and  sitz-baths,  vaginal  in- 
jections, and  ergot,  with  bromide  of  potassium.  Instead  of  the 
ergot  and  bromide,  fifteen  to  twenty  grain  doses  of  phenacetine 
every  six  to  eight  hours  may  be  given.  In  the  neuralgic,  let  the 
patient  exercise  in  the  open  air,  and  give,  iron,  quinine,  and 
other  tonics.  Pozzi  has  found  the  tincture  of  pulsatilla,  given 
some  days  before  the  period,  in  five -drop  doses,  three  times  daily, 
quite  efficient  in  the  neuralgic  form  of  young  women.  In  the 
membranous,  dilatation  of  the  cervix  just  before  the  menstrual 
period,  is  sometimes  effective.  In  the  ovarian  type,  the  bromides 
are  the  most  serviceable.  In  any  variety,  where  the  pain  re- 
quires it,  potassium  bromide  and  chloral  may  be  given,  with 
mustard  plasters  applied.  As  palliative  treatment  for  the  pain, 
give  asafceticla,  musk,  tincture  of  cannabis  indica,  belladonnae  or 
hyoscyamus.  Oxalate  of  cerium  has  been  extolled.  Wylie 
praises  electricity,  he  inserts  the  positive  pole  in  the  cervix. 
Laudanum  and  valerian  douches  often  afford  relief  when  all 
other  remedies  fail.  Nitro- glycerine  and  amyl  nitrite  are  excel- 
lent for  spasmodic  cases  (Pozzi). 


DYSMENORRHEA DYSPEPSIA.  161 

PRESCRIPTIONS  FOR  DYSMENORRHEA, 

R     Tincturse  cardamonii  comp 5ss. 

Spiritus  chloroformi ZTT.xx. 

Liq.  ammonii  acetatis ^ss. 

Tincturse  belladonna?  ITC.x. 

Aquse  cinnamomi q.  s.,  ad oj- — M. 

Sig. :     For  one  dose.     (In  congestive  and  spasmodic).       — Pozzi. 

R     Liq.  ammonii  acetatis £iv. 

Sig. :     A  tablespoonful  every  two  or  three  hours,  with  the  fol- 


lowing: 

R     Pulv.  ipecac gr.  iv. 

In  pil.  no.  xii.  div. 
Sig. :     One  every  two  or  three  hours.  — Emmet. 

R     Extracti  opii gr.  v. 

Extracti  cannabis  indica 

Extracti  byoscyami aa gr.  x. 

Pulv.  Camphora? gr.   xxv. — M. 

Ft.  massa  et  in  pil.  no.  x.  div. 
Sig.:     A  pill  two  or  three  times  daily.  — McLane. 

DYSPEPSIA. 

Is  difficult  or  painful  digestion.  It  is  usually  chronic.  A 
disordered  digestion,  lasting  for  a  short  time,  is  called  indiges- 
tion. 

Causes. — Dyspepsia  is  often  an  inherited  condition.  It  may 
result  from  a  deficiency  in  the  quantity  of  gastric  juice  secreted, 
due  to  exhausting  discharges,  venereal  excesses/  masturbation, 
leucorrhoea  and  phthisis,  and  from  the  excessive  use  of  narcotics, 
the  tannin  of  tea,  and  the  nicotine  of  tobacco.  It  may  result 
from  an  excess  in  the  gastric  secretion,  due  to  chronic  hepatic 
and  cerebral  diseases,  and  to  gout.  It  may  result  from  a  change 
in  the  quality  of  the  gastric  juice,  due  to  ulcer  and  cancer  of  the 
stomach,  gout,  rheumatism,  diseases  of  the  kidneys,  uterus  and 
gall-bladder.  Dyspepsia  may  result  from  pressure  on  the  stom- 
ach by  tight  lacing,  from  positions  assumed  by  shoemakers, 
needlewomen,  writers,  etc.     It  may  result  from  mental  emotion, 


162  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

prolonged  mental  labor,  anxiety,  deficient  or  excessive  physical 
labor,  excess  of  starchy  food,  or  from  deficiency  of  meats,  badly 
cooked  food,  too  rapid  eating,  etc.  (Loomis). 

Symptoms. — The  most  constant  s}'mptom  is  an  abnormal 
appetite;  it  may  be  lost,  increased,  or  perverted.  There  is  a 
weight,  dull  pain,  and  a  sense  of  burning  in  the  epigastrium 
after  the  ingestion  of  food,  accompanied  by  flatulence,  heartburn, 
gastralgia,  constipation  or  diarrhoea,  a  dull  headache,  and  languor. 
Indiscretion  in  eating  or  drinking  is  apt  to  bring  on  an  attack  of 
sick  headache.  There  is  frequently  a  bitter  taste  in  the  mouth. 
In  some  dyspeptics  the  breath  has  a  very  offensive  odor.  Py- 
rosis, palpitation,  dyspnoea  and  a  severe  pain  referred  to  the 
heart  (which  makes  the  patient  think  he  has  heart  disease),  may 
be  present.  In  some  cases  there  is  ringing  in  the  ears,  spots 
before  the  eyes,  and  vertigo.  When  in  any  case  the  dyspepsia 
has  lasted  a  long  time,  chronic  gastric  catarrh  will  almost  always 
be  developed  (Loomis). 

Prognosis. — Dyspepia  in  most  cases  can  be  cured,  but  the 
cure  depends  for  the  most  part  on  the  will  of  the  patient. 

Treatment. — First,  if  possible,  remove  the  cause.  When  the 
gastric  juice  is  deficient  in  quantity,  hydrochloric  acid  and  pepsin 
are  indicated.  The  vegetable  bitters  are  efficient  in  these  cases, 
and  may  be  combined  with  alcoholic  stimulants.  When  acid 
risings  occur  after  ingestion  of  food,  and  are  due  to  active  fer- 
mentation, the  sulphite  of  soda,  or  salicylic  acid  immediately 
after  meals  may  prevent  such  changes.  Saline  waters  will  aid. 
When  there  is  great  irritability  of  the  stomach,  bismuth  acts 
almost  as  a  specific,  and  should  be  given  in  twenty  grain  doses 
before  eating.  Creosote,  codeia,  oxalate  of  cerium,  and  morphia 
may  be  employed  to  arrest  vomiting.  Dyspeptics  should  never 
wear  corsets  or  belts  about  the  abdomen.  They  should  retire 
and  rise  early,  eat  slowly,  and  masticate  well.  No  mental  or 
phvsical  work  should  be  performed  directly  after  or  before 
eating.  Horseback  riding  and  walking  in  the  open  air  should 
be  insisted  upon.  A  change  of  scene  and  climate  works  rapid 
cures  in  many  instances.  Dyspeptics  should  take  a  cold  sponge - 
bath  morning  and  evening  (Loomis).  A  small  quantity  of  acid 
wine  at  dinner  is  a  good  stimulant  to  the  digestive  function.     A 


DYSPEPSIA.  163 

moderate  dose  of  whiske}T,  taken  before  nieals,  is  a  capital  remedy 
to  promote  the  appetite  and  the  digestion  (Bartholow). 

PRESCRIPTIONS  FOR  DYSPEPSIA. 

R      Ammonii  salicylates 5ij- 

Syrupi  aurantii  cort §j. 

Aquae  mentha?  pip ad 5iv. — M. 

Sig. :  A  tablespoonful  half  an  hour  before  meals.  (In  fermentative 
dyspepsia.)  — Sullivan. 

R     Tincturse  capbici IH.xvj. 

Tinctura?  nucis  vomica? •■31j- 

Tinctura?  gentiana?  comp ad...3ij. — M. 

Sig. :  A  teaspoonful  in  water  three  times  daily,  with  i  gr.  aloin 
at  bedtime,  avoiding  starchy  diet.  (For  aggravated  dyspepsia  with 
constipation.)  — DaCosta. 

R     Bismuthi  subnitratis 

Sodii  bicarbonatis 

Pul v.  cubebse — aa 3j . 

Pulv.  zingiberis gr.  xx. — M. 

In  pulv.  no.  xii.  div. 
Sig. :     A  powder  in  a  wineglassful  of  water  before  each  meal. 

—Clark. 

R     Tincturse  opii  deodorat gtt.  xij. 

Magnesii  calcinat gr.  xij.-xxiv. 

Sacchari  albi oj- 

Aqua?  anisi §iss. — M. 

Sig.:  Shake  bottle.  One  teaspoonful  every  two  hours  to  a  child 
one  year  old,  until  relieved.  — J.  Lewis  Smith. 

R     Bismuthi  subnitratis...., ^iss. 

Mucil  acacia? §j. 

Sodii  bicarbonatis giss. 

Infusi  calumba? ad oviij. — M. 

Sig.:  Two  tablespoonfuls  before  meals.  (Irritative  dyspepsia 
with  raw  tongue.)  — Fothergill. 

Buttermilk- cure  may  be  substituted  for  the  milk- cure  in 
cases  of  stomach  disease  (Bartholow). 

Actaea  (cimicifuga)  is  recommended  for  the  dyspepsia  of 
drunkards. 


164  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

DACTYLITIS.     (Syphilitic). 

Is  guininy  in  character,  and  hence  belongs  to  the  later  stages 
of  syphilis.  It  is  a  rare  affection.  The  swelling  usually  termin- 
ates abruptly,  and  is  sometimes  very  great.  There  is  no  com- 
plaint of  pain.  The  skin  is  natural  or  bluish  from  venous 
obstruction. 

Treatment. — Is  that  of  tertiary  syphilis. 

DANDRUFF.     (See  Pityriasis). 

DERBYSHIRE  NECK.     (See  Goitre.) 

DROWNING. 

Remove  from  the  mouth  and  nostrils  all  obstructions  to  the 
free  passage  of  air  to  the  lungs ;  loosen  clothing  about  the  chest. 
Extend  the  arms  in  the  direction  of  the  body  above  the  head, 
and  when  the  capacity  of  the  chest  is  thus  enlarged,  throw  fresh 
air  into  the  lungs  by  a  flexible  tube  passed  into  the  trachea,  and 
then  replace  the  arms,  pressing  firmly  upon  the  sides  and 
sternum.  These  motions  may  be  repeated  ten  or  fifteen  times 
per  minute.  A  strong  solution  of  ammonia  may  be  passed  under 
the  nose. 

EARACHE. 

Treatment. — An  excellent  application  in  earache  is  the  fol- 
lowing: 

R     Morphia  sulphatis gr.  iv. 

Aquse  destillatse Sj. — M. 

Sig. :     Fill  the  external  meatus  with  the  solution.     — Bartholow. 

Cocaine,  five  to  ten  per  cent,  solution,  is  the  most  effective 
remedy  for  earache  (Bartholow). 

The  external  auditory  meatus  filled  with  water  as  hot  as  can 
be  borne  is  effective. 

Counter -irritation  by  blistering  fluid  or  croton-oil  liniment 
behind  the  ear  often  removes  earache  (Ringer). 


ECZEMA.  165 

ECZEMA. 

Is  a  non-contagious,  vesicular,  cutaneous  eruption,  with 
cedeuia,  pustules,  exudation,  or  fission,  and  usually  much  itching. 
Eczema  is  catarrh  of  the  skin  (Tilbury  Fox).  It  may  safely  be 
affirmed  that  very  few  persons  pass  through  life  without  suffering 
from  it  in  some  measure.  It  is  by  far  the  most  frequent  of  the 
diseases  of  the  skin. 

Causes. — May  be  constitutional  or  local,  or  both  combined. 
It  often  happens  that  the  constitutional  cause  has  disappeared 
before  the  patient  is  seen,  and  the  affection  remains,  owing  to 
the  skin  having  contracted  a  bad  habit.  The  chlorotic,  the  rach- 
itic, the  scrofulous,  and  the  debilitated,  are  very  liable  to  be  at- 
tacked. Eczema  may  be  caused  by  digestive  derangement,  and 
the  parts  most  frequently  attacked  are  the  face,  lips,  arms  and 
hands.  Improper,  insufficient  or  bad  food,  is  very  apt  to  call  it 
forth.  It  is  often  seen  in  infants  whose  mothers  have  a  deficient 
or  watery  secretion  of  milk.  A  fruitful  cause  of  eczema  is  de- 
ficient excretion,  constipation,  or  defective  elimination  by  the 
kidneys.  A  predisposing  cause  is  rheumatism.  Diabetes  mel- 
litus  may  cause  an  eczema  of  the  genital  organs.  Long- continued 
mental  excitement,  anxiety,  grief,  or  over -study,  may  cause  it. 
Eczema  is  met  with  at  all  periods  of  life,  but  occurs  most  fre- 
quently in  children.  Derangement  of  the  uterus  or  its  append- 
ages, irritation  of  ascarides,  or  tapeworm,  stricture  of  the  urethra, 
dentition,  internal  medicines,  exposure  to  great  heat,  or  to  ex- 
treme cold,  or  to  acrid  substances  (as  in  the  case  of  grocers, 
bakers,  bricklayers,  washerwomen,  cooks,  smiths,  etc.),  may 
cause  eczema.  Varicose  veins,  pressure  by  tumors,  garters,  and 
trusses,  stimulating  liniments,  as  croton-oil,  lice,  fleas,  bugs,  irri- 
tation of  the  razor,  and  of  discharges  from  the  genito- urinary 
organs,  anus,  meatus  auditorius,  nostrils  and  mouth,  are  common 
causes  of  eczema.  The  irritation  of  poisonous  dyes  used  in 
some  of  the  colored  socks  in  the  market,  is  apt  to  give  rise  to  a 
variety  of  eczema  of  the  feet. 

Symptoms. — There  are  four  symptoms  which  are  almost  in- 
variably present  to  a  greater  or  less  extent,  namely:  1.  Infiltra- 
tion of  the  skin.      2.   Exudation  on  the  surface  of  the   skin.     3. 


166  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Formation  of  crusts.  4.  Burning  heat,  or  itching.  The  infiltra- 
tion is  due  to  the  transudation  of  serum  from  the  blood-vessels 
into  the  tissues.  The  exudation,  or  "weeping"  may  take  place 
constantly,  or  at  intervals;  it  is  then  called  moist  eczema.  If 
there  is  no  exudation,  it  is  called  dry  eczema.  The  crusts,  com- 
posed of  hardened  exudation,  are  more  or  less  present.  If  the 
patient  be  cleanly  in  his  habits,  the  exuded  matter  is  washed  off, 
and  the  crusts  may  be  wanting;  and,  vice  versa,  the  crusts  may 
be  thick.  When  the  patches  of  eruption  are  acutely  inflamed, 
burning  heat  is  complained  of.  When  the  disease  becomes 
chronic,  the  burning  heat  is  replaced  by  itching.  The  use  of 
stimulating  food  or  drink,  or  on  getting  warm  in  bed,  or  the 
slightest  touch  of  the  part,  gives  rise  to  an  irresistible  desire 
to  scratch.  Patients  derive  much  positive  pleasure  from  scratch- 
ing the  part.  Instead  of  itching,  formication  is  sometimes  com- 
plained of.  Scratching  always  aggravates  the  disease.  The 
elementary  lesion  is  of  great  importance.  This  may  be:  1.  An 
erythematous  state  of  the  skin.  2.  A  vesicle.  3.  A  pustule. 
4.  A  papule,  or  a  mixture  of  all  these  lesions.  When  the  ele- 
mentary lesion  is  an  erythematous  state  of  the  skin,  the  disease 
commences  as  a  simple  inflammatory  redness  of  the  surface,  with- 
out, at  first,  infiltration  or  exudation.  The  vesicular  and  pustular 
forms  of  eczema  often  form  upon  an  erythematous  ground. 

Prognosis.— Is  rarely  serious.  Attacks  of  eczema  vary  much 
in  their  duration.  Some  cases  get  well  without  treatment  in  a 
few  weeks,  others  last  for  months  or  even  years.  When  the 
eruption  is  localized  it  is  more  difficult  of  cure.  Relapses  are 
very  much  to  be1  feared. 

Treatment. — Some  cases  may  be  cured  by  either  constitu- 
tional or  local  treatment,  but  generally  it  is  advisable  to  employ 
a  combination  of  both. 

Constitutional  Treatment.— Purgatives  and  aperients  are  often 
useful,  but  are  merely  aids  to  Other  treatments  If  the  tongue  is 
loaded,  the  appetite  bad,  the  liver  torpid  and  the  bowels  costive, 
the  following  formulae  may  be  used : 

R     Hydrargyri  chloridi  mitis gr.  xx. 

Pulv.  scammonii  comp gr.  xL. — M. 

Div.  in  pulv.  iv. 
Sig.:     One  every  week.  — Anderson. 


ECZEMA.  167 

R     Quinias  sulphatis gr.  xij. 

Pulv.  rhei gr.  xxxvj. 

Hydrarg.  cum  cretse , gr.  xx. 

Sacchari  purificati gr.  xx. — M. 

In  pulv.  no.  xii.  div. 
Sig. :     Two  daily.     The  dose  to  be  so  regulated  that  the  patient 
has  at  least  one  full  natural  evacuation  per  day.     Or  the  following 
may  be  given  : 

B     Quinine  sulphatis gr.  xLviij. 

Ferri  sulphatis 3iij . 

Acidi  sulphurici  dil .  ...giss. 

Magnesii  sulphatis siij . 

Sy rupi  zingiberis 

Tinct.  aurantii — aa giss. 

Infusi  calumbas ad sxxiv. — M. 

Sig. :     A  tablespoonful  in  a  wineglassful  of  water  thrice  daily. 

In  some  cases  of  eczema,  diuretics  are  indicated.  In  strum- 
ous subjects,  nourishing  food,  stimulants  in  moderation,  and 
tonics  are  our  sheet  anchors.  Severe  cases  of  eczema  have  been 
cured  by  the  administration  of  cod-liver  oil  and  syrup  of  the 
iodide  of  iron.  Twenty  drops  of  the  syrup  of  iodide  of  iron  in 
a  teaspoonful  of  cod- liver  oil  thrice  daily,  and  the  dose  to  be 
gradually  increased  to  a  tablespoonful,  may  be  given.  Cod-liver 
oil  may  be  applied  locally  with  benefit.  Of  nerve  tonics,  those 
which  are  most  likely  to  be  useful  are  strychnia  and  arsenic  (in 
form  of  Fowler's  solution).  In  chronic  eczema,  electricity  is 
used  with  some  benefit.  The  diet  is  of  great  importance,  and 
must  be  carefully  regulated. 

Local  Treatment. — Some  cases  of  eczema  are  local  diseases 
throughout  their  whole  course,  being  due  to  local  irritation,  and 
"are  benefited  more  by  local  than  constitutional  treatment.  The 
disease  sometimes  remains  from  habit.  Our  skins  have  the  same 
tendency  as  ourselves  to  contract  bad  habits.  The  first  thing  is 
to  remove  the  crusts  with  oil.  Then  dust  the  parts  with  absorb- 
ent powder  two  or  three  times  daily.  Soothing  ointments  are 
indicated,  such  as  follows  : 

R     Zinci  oxidi 5J- 

Acicli  oleici §viij . 

Vaselini §ix. — M. 

Sig.:     Apply  to  parts.  — Anderson. 


168  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Pulv.  camphorse gr.  xx. 

Pulv.  zinci  oxidi 3ij. 

Glycerini 3.j. 

Adipis  benzoati §j . 

Cochinillini ..  gr.  j . 

Oleirosse ZH-j— M. 

Sig. :     Apply  to  face  two  or  three  times  daily.  — Anderson. 

R     Hydrargyri  perchloridi gr.  xij. 

Acidi  hydrocyanic!  dil gij. 

Glycerini 3iij . 

Eau  de  cologne ad  5yj. — M. 

Sig.:     Sponge  the  parts  two  or  three  times  daily.        — Anderson. 

Of  all  the  local  means  for  the  removal  of  limited  eczematous 
eruptions,  none  are  superior  to  blistering.  The  best  and  safest 
blistering  agent  is  cantharides.  The  local  varieties  of  eczema 
are:  of  the  head,  hairy  portions  of  the  face,  lips,  edges  of  the 
eyelids,  nostrils,  auricle,  and  external  auditory  passage,  the  flexor 
surfaces  of  the  joints,  the  hands  and  feet,  the  legs  and  the  geni- 
tal organs. 

PRESCRIPTIONS  FOR  ECZEMA. 

R     Acidi  citrici gr.  xv. 

Aquae  lauro-cerasi 3] . 

Olei  rusci  (birch) gtt.  xv. 

Ungt.  aquae  rosse 3x. — M. 

Sig.:     Use  thrice  daily.     Use  starch  powder  between  the  applica- 
tions.    Carefully  attend  to  diet.     (For  acute  eczema.)  — Monin. 

R     Glyceriti   amyli £viiss. 

Acidi  tannici 

Hydrargyri  chlo.  mit aa gr.  xv. — M. 

Sig.:     Apply    morning    and    evening.       (In    dry   eczema    with 
itching.)  — Vidal. 

R     Ungt.  hydrargyri  oxidi  rubri ^ij. 

Ungt.  sulphuris 3ij- 

Acidi  carbolici... gr.  iij. 

Unguenti  simplicis §ss. — M. 

Sig.:     Apply  to  the  afiected  parts.     (In  chronic  eczema.) 

— DaCosta. 

R     Tincturae  belladonnas 5ss. 

Sig. :     Five  drops  thrice  daily  to  a  child  of  two  years.     (In  in- 
fantile eczema.)  — Bartholow. 


ECZEMA EMISSIONS.  169 

R     Pulv.  acidi  salicylici gr.  xv.-xxx. 

Pulv.  zinci  oxidi 

Pulv.  amyli aa giij. 

Vaselini  puri 3vj . — M. 

Ft.   nngt 

Sig. :     Apply  locally,  and  cover  with   cotton  after  rubbing  oint- 
ment in.     (In  papulous  or  squamous  eczema.)  — Lassar. 

R     Infusi  cinchonas |vj. 

Aquas  calcis gixss. 

Tinct.  lupulinae 

Succi  conii aa gij . — M. 

Sig.     A   wineglassful  thrice  daily.      (In  chronic  eczema  of  the 
aged.)  — Neligan. 

R     Ferri  et  ammonii  citratis gj. 

Potassii  citratis gij. 

Liquor  potassii  arsenitis 5!— ij . 

Tinct.  nucis  vomicae gij. 

Tinct.  cinchonas  corap ad §iv. — M. 

Sig.:     A  teaspoonful  in  water  after  meals,  as  a  tonic  and  altera- 
tive.    (In  eczema.)  — Bulkley. 

R     Resorcin  

Zinci  oxidi aa 3j. 

Ungt.  aquas  rosse gx. — M. 

Ft.   ungt 

Sig. :     Apply  locally.     (In  chronic  indurated  eczema  of  infants.) 

— Fleisburg. 

EMISSIONS.     (Involuntary  Seminal.) 

By  involuntary  seminal  emissions  is  meant  the  ejaculation 
of  semen  and  the  venereal  orgasm  without  any  voluntary  effort, 
either  natural  or  unnatural. 

Involuntary  emissions  occurring  during  sleep  are  common, 
taking  place  with  erotic  dreams.  Occurring  after  intervals  of 
several  days  in  persons  of  continent  habits,  they  are  physiologi- 
cal rather  than  pathological.  They  denote  simply  a  certain 
amount  of  functional  activity  of  the  generative  organs.  They  do 
not  imply  a  morbid  condition  nor  do  they  lead  to  any  morbid 
effects.  They  occur  especially  when  habitual  sexual  intercourse 
is  interrupted  from  any  cause.  Under  these  circumstances  they 
are  manifestations  of  health  rather  than  of  disease. 


170  A    COMPENDIUM ;  OF    PRACTICAL     MEDICIJSTE. 

Occurring  more  frequently,  the  emissions  denote  a  morbid 
erethism  and  weakness  of  the  organs  of  generation.  They  occur 
sometimes  nightly  and  sometimes  even  repeatedly  during  the 
same  night.     They  then  call  for  remedial  measures. 

Occurring  in  persons  debilitated  from  any  cause,  they  may 
take  place  without  any  erection  and  with  little  or  no  venereal 
excitement.  They  occur  sometimes  during  the  day,  and  are  called 
diurnal.  Venereal  excesses,  or  unnatural  abuse,  are  the  causes  of 
this  morbid  frequency.  The  mind  becomes  depressed.  The 
patient  fancies  he  is  impotent,  his  constitution  ruined,  and  that 
there  is  clanger  of  insanity.  They  go  from  one  physician  to  an- 
other, and  upon  jDatients  of  this  class  quacks  prey  largely  (Flint). 

Pollution  is  a  term  applied  to  involuntary  seminal  emis- 
sions, attended  by  venereal  orgasm,  more  or  less  marked.  Dr. 
Keyes  writes  as  follows  of  pollution :  "  Nocturnal  pollutions 
are  exceedingly  common.  They  usually  accompany  erotic 
dreams." 

Nocturnal  emissions  in  moderation  are  entirely  natural,  and 
by  no  means  a  sign  of  disease.  Their  frequency  compatible 
with  health  varies  with  the  purity  of  mind  and  sexual  vigor  of 
the  patient.  A  man  who  is  happily  married  rarely  has  noctur- 
nal emissions  while  living  with  his  wife,  but,  if  he  leaves  her  for 
several  weeks,  it  is  natural  and  entirely  the  rule  that  there 
should  be  a  formation  and  collection  of  semen,  which  distending 
the  seminal  vesicles,  excites  erotic  fancies,  and  escapes  at  the 
conclusion  of  a  dreain.  Any  man  suffering  from  un gratified 
sexual  desire  is  normally  in  a  condition  demanding  relief  for  his 
over  distended  seminal  vesicles,  and,  if  that  relief  be  not  afforded 
in  some  way  by  the  patient,  it  will  come  spasmodically  during 
sleep.  Occasionally  nocturnal  emissions  may  be  over-frequent, 
and  indicate  a  condition  of  irritation  in  the  deep  Urethra  which 
requires  treatment  (Keyes). 

Treatment.— When  emissions  do  not  exceed  three  times 
weekly  they. should  be  disregarded.  Where  they  become  very 
frequent,  as  nightly  or  several  times  a  night  for  a  considerable 
time,  there  should  be  an  attempt  made  to  correct  the  habit. 
Purify  his  thoughts,  elevate  his  tone,  and  get  him  if  possible 
happily  married.     The  patient  should  endeavor  to  sleep  soundly 


EMISSIONS..  171 

by  tiring  himself  out  through  the  clay  by  physical  work.  Dry 
friction,  cold  bath  and  cold  douche  locally  are  useful.  He 
should  sleep  on  a  hard  bed  lightly  covered.  The  stomach  should 
not  be  full  on  retiring.  Lying  on  the  back  with  the  bladder  full 
of  urine,  tends  to  beget  erections.  To  avoid  this,  the  patient 
should  tie  a  towel  around  his  waist  on  retiring,  with  a  hard  knot 
in  the  back  over  the  spine.  Besides  the  above  means,  bromide 
of  potassium,  camphor  and  lupulin  may  be  given  internally, 
with  strychnine  and  a  mineral  acid,  and  locally  decided  advan- 
tage may  be  derived  from  the  gentle  use  of  the  steel  sound,  as  in 
neuralgia  of  the  vesical  neck.  Mechanical  devices  appear  from 
time  to  time  for  treating  pollution,  but  they  usually  do  more 
harm  than  good.  Keyes  used  an  appliance  which  started  a 
battery  and  gave  an  electric  shock  in  the  back  when  erection 
came  on.  Verneuil  used  a  similar  instrument  which  caused  a 
bell  to  ring  when  erection  came  on.  A  ring  which  lightly  encir- 
cles the  penis,  but  when  distended  by  erection  causes  pain  and 
awakens  the  j)atient  has  been  used.  Marriage  is  always  remedial 
in  physiological  cases  (Keyes). 

PRESCRIPTIONS  FOR  EMISSIONS. 

B     Potassii  brornidi 3j. 

Sodii  bicarbonatis gr.  xv. 

Infusi  digitalis 5ss. 

Atropine  sulphatis gr.  ^ . — M. 

Sig.:     To  be  taken  at  bedtime.  — Gross. 

ft     Lupulinse gr.  x. 

Pulveris  camphorre gr.  vj. 

.  Extracti  belladonnse gr.  ij. — M. 

In  pil.  no.  xii.  div. 
Sig.:     One  pill  thrice  daily.  — Bartholow. 

R     Tincturae  cantharidis gij. 

Tincturse  ferri  chloridi gvj. — M. 

Sig.:     Twenty  drops  in  water  thrice  daily.  — Wood. 


172  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

EMPHYSEMA.     (  Pulmonary. ) 

Enrphvsenia  in  general  signifies  the  presence  of  air  in  the 
interstitial  connective  tissue.  In  the  lungs,  however,  there  are  two 
kinds  of  emphysema — interlobular  and  vesicular;  the  former 
arises  from  rupture  of  the  air-cells,  causing  a  communication  be- 
tween them  and  the  interlobular  connective  tissue,  and  the  latter, 
the  more  common,  consists  in  an  abnormal  accumulation  of  air 
within  the  air-cells. 

Emphysema  is  essentially  a  chronic  affection;  it  comes  on 
slowly,  and  when  once  developed  is  permanent  (Loomis  and 
Flint'). 

Causes. — Are  forced  expiratory  efforts,  the  glottis  being 
closed  or  narrowed,  as  in  violent  coughing,  straining  at  stool, 
etc.  It  is  developed  in  the  upper  lobes  of  the  lung.  Various 
injuries  and  diseases  of  the  chest  which  limit  the  movements  of 
the  lungs,  as  curvature  of  the  spine,  pleural  adhesions,  hydro - 
thorax,  tumors,  pneumonia,  perforating  wounds  of  the  chest,  or 
injury  of  the  lung  by  the  extremity  of  a  fractured  rib,  may 
cause  emphysema  of  the  lung  (Loomis  and  Flint). 

Symptoms. — The  most  prominent  and  constant  subjective 
symptom  of  emphysema  is  dyspnoea,  which  is  increased  by  physi- 
cal exercise.  It  is  worse  during  the  cold  of  winter.  There  is 
often  a  smothering  sensation  in  the  chest.  There  is  no  fever. 
The  pulse  is  feeble,  and  the  body  cool  and  cyanotic.  In  extreme 
cases,  lividity  is  marked.  Usually  there  is  no  pain  in  the  che>t. 
The  nostrils  are  distended,  the  voice  is  feeble,  and  the  capillary 
circulation  is  imperfect.  The  temperature  of  the  body  is  usually 
sub-normal.  There  is  distension  of  the  jugular  veins,  and  ver- 
tigo is  common.  There  may  be  oedema  of  the  feet  and  ankles. 
Emphysematous  patients  are  especially  liable  to  hemorrhoids. 

Physical  Signs. — On  inspection,  it  will  be  noticed  that  the 
chest  is  "barrel- shaped."  The  lower  portion  of  the  chest  seems 
contracted.  The  apex  of  the  heart  will  be  found  beating  lower 
down  than  normal,  and  more  toward  the  median  line.  On  pal- 
pation, the  vocal  fremitus,  varies.  In  senile  emphysema,  the  vocal 
fremitus  is  usually  increased.  The  percussion  sound  is  vesiculo- 
tympanitic.      On    auscultation,   the   inspiratory  sound  is   either 


EMPHYSEMA EMPYEMA.  173 

short  or  feeble,  or  actually  suppressed,  while  the  expiratory  is 
greatly  prolonged  (Looruis). 

Prognosis. — It  rarely,  if  ever,  destroys  life,  but  when  once 
developed,  is  never  recovered  from. 

Treatment. — As  this  disease  is  incurable,  our  treatment  must 
be  palliative.  Iron  and  the  sulphate  of  quinine  in  small  doses, 
may  be  given  with  benefit.  Cod-liver  oil,  bitter  infusions,  min- 
eral acids  and  stimulants  are  all  useful.  The  diet  should  be  of 
the  most  nutritious  character,  and  composed  largely  of  animal 
food.  Exercise  in  the  open  air  should  be  taken.  Quebracho  is 
a  useful  drug  for  emphysema.  For  the  bronchitis  which  accom- 
panies emphysema,  iodide  of  potassium  in  five  to  ten  grain  doses 
thrice  daily  is  serviceable.  For  the  asthmatic  attacks,  morphine 
and  atropine  are  useful. 

PRESCRIPTIONS  FOR  EMPHYSEMA. 

B     Liquoris  potassii  arsenitis gtt.  ij. 

Potassii  iodidi  gr.  x. 

Syrupi  tolu 5ss. 

Aquas 5ss. — M. 

Sig.:     This  dose  t.  i.  d. 

R     Ammonii  iodidi 5j- 

Liquoris  potassii  arsenitis 5ss. 

Syrupi  tolutan Sj • — M. 

Sig.:     A  teaspoonful  every  four  hours.  — Bartholow. 

EMPYEMA. 

Called,  also,  suppurative  pleurisy,  or  pyothorax,  is  charac- 
terized by  the  accumulation  of  a  purulent  liquid  in  the  pleural 
cavity.     It  is  usually  confined  to  one  side. 

Cause. — Is  not  always  known.  It  may  be  of  traumatic  ori- 
gin.* It  may  result  from  exhausting  diseases  or  debility.  It  often 
complicates  acute  and  chronic  infectious  diseases.  Chronic  tuber- 
cular pleurisies  are  very  apt  to  be  suppurative  in  character.  It 
may  be  secondary  to  abscess  of  the  liver,  or  in  the  abdominal 
cavity,  or  to  chronic  phthisis.  It  is  sometimes  secondary  to  lobar 
pneumonia  (Loomis). 


174  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — If  the  inflammatory  process .  is  acute  there  will 
be  chills,  fever,  a  rapid  pulse,  severe  pain  in  the  affected  side, 
great  prostration,  anxious  expression  and  typhoid-symptoms; 
these  cases  usually  terminate  fatally  within  two  or  three  weeks. 
The  symptoms  of  chronic  empyema  are  very  often  obscure.  The 
patient  rarely  suffers  from  local  pain — there  is  simply  a  sense  of 
uneasiness,  or  weight  in  the  affected  side,  loss  of  flesh  and 
strength,  pale  countenance,  diurnal  chill  followed  by  profuse 
sweats.  There  are  cough,  weak  voice,  dyspnoea,  etc.  A  positive 
diagnosis  may  be  made  by  an  exploratory  puncture.  If  an  em- 
pyema is  about  to  open  externally,  it  will  protrude  between  the 
ribs,  and  give  a  sense  of  fluctuation,  and  become  red.  It  may 
open  into  a  bronchial  tube  and  be  followed  by  profuse  purulent 
expectoration.  The  chest  walls  gradually  retract.  It  may  open 
into  the  peritoneal  cavity  and  be  followed  by  a  fatal  peritonitis 
(Loomis). 

Prognosis. — U  nf  a  vorable . 

Treatment. — An  opening  should  be  made  at  the  bottom  of 
the  pleural  sac,  allowing  the  pus  to  escape  freely.  The  pleural 
cavity  should  be  daily  cleansed  by  the  injection  of  tepid  water 
to  which  a  very  small  quantity  of  carbolic  acid  (one  per  cent.)  is 
added.  Aspiration  should  first  be  tried.  In  children  simple 
aspiration  frequently  effects  a  cure  (Flint).  If  aspiration  is  re- 
sorted to,  a  large- sized  needle  should  be  used,  and  only  a  small 
portion  of  the  fluid  removed  the  first  time.  Aspirate  every  third, 
fourth  or  fifth  day.  Never  continue  the  removal  of  pus  in  em- 
pyema after  the  patient  complains  of  constriction  in  breathing. 
If  a  permanent  opening  is  to  be  made,  let  it  be  made  in  the  ax- 
illary line  in  the  seventh  or  eighth  intercostal  space,  and  a 
quarter -inch  rubber  drainage  tube  should  be  introduced,  and  so 
fastened  that  it  will  remain.  The  pleural  cavity  should  not  be 
washed  out  (Loomis).  Tonics,  such  as  quinine,  cod-liver  oil 
and  iron  are  always  indicated  and  exercise  in  the  open  air. 

PRESCRIPTIONS  FOR  EMPYEMA. 

R     Misturse  ferri  et  ammon  acetat §iv. 

Sig.:     One  to  two  teaspoonfuls  four  times  daily,  with  quinine  and 
stimulants.     (In  chronic  cases.)  — DaCosta. 


ENDOCARDITIS.  175 

R     Liquor  iodinii  corap %j. 

Aquae  destillata? §xv. — M. 

Sig. :     Inject  after  aspirating  the  pus.  — Bartholow. 

R     Quinise  sulphatis ^ij. 

Aqua? Sxij . — M. 

Sig. :     Inject  after  evacuating  the  pus.  — Ringer. 

R     Aqua?  chlorinii 5J. 

Aqua?  destillata? six, — M. 

Sig.:     To  wash  out  the  pleural  cavity  after  the  evacuations  of 
the  pus.  — Ringer. 

ENDOCARDITIS. 

Is  an  inflammation  of  the  endocardium.  In  adults  the  left 
heart  is  oftenest  affected.  The  inflammation  is,  in  the  majority 
of  cases,  situated  on  the  valves  and  chordae  tendineae.  Vegeta- 
tions appear  upon  the  endocardium.  These  vegetations  may 
attain  the  size  of  a  pea  and  are  favorable  points  for  the  detach- 
ment of  emboli  (Flint). 

Causes. — Primary,  or  idiopathic  endocarditis  is  extremely 
rare.  It  is  secondary  to  pleuritis,  pneumonia  and  pericarditis, 
but,  very  more  frequently,  secondary  to  acute  rheumatism.  About 
one -third  of  the  cases  of  acute  rheumatism  are  complicated  by 
endocarditis  (Bartholow).  It  is  produced  by  the  same  cause 
that  produced  the  rheumatism,  and  not  by  metastasis  (Flint). 

Symptoms. — The  patient  may  complain  of  an  obscure  sense 
of  distress  in  the  praecordia,  not  amounting  to  pain.  The  action 
of  the  heart  may  be  morbidly  excited — palpitation.  There  is  an 
endocardial  murmur.  The  murmur  is  of  a  soft,  or  bellows  char- 
acter. It  accompanies  the  first  sound  of  the  heart.  It  is  heard 
loudest  at  or  near  the  apex  of  the  heart  (Flint).  There  may 
be  paroxysmal  dyspnoea,  the  face  may  be  flushed  and  even  cyanotic 
(Looniis). 

Prognosis. — The  danger  is  not  immediate,  but  remote. 

Treatment. — Sinapisms  and  stimulating  liniments  to  the 
praecordia  are  indicated.  Alkaline  remedies  lessen  the  liability 
to  fibrinous  deposits  upon  the  valves.  The  patient  should  avoid 
physical  exertion,  mental  excitement,  a  stimulating  diet,  and  the 
use  of  alcohol.  A  tablespoonful  of  the  infusion  of  digitalis 
should  be  given  every  four  hours  (Flint  and  Bartholow). 


176  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  ENDOCARDITIS. 

R     Tincturse  digitalis 3J  • 

Sig.:     Ten  or  fifteen  drops  every  four  hours.     (When  heart's  ac- 
tion is  irregular).  — DaCosta. 

R     Tincturse  aconiti  radicis Sss. 

Sig. :     One  drop  every  hour  or  two.  — Ringer. 

R     Lini  farinse 

Aqua?  bullientis aa q.  s. — M. 

Ft.  cataplasma. 
Sig.:     Apply  over  the  heart  as  hot  as  can  be  borne.     — DaCosta. 

ENTERITIS. 

Is  a  general  term  applied  to  a  catarrhal  inflammation  of  the 
intestinal  mucous  membrane.     It  may  be  acute  or  chronic. 

Causes. — Direct  irritation  of  the  mucous  membrane  by  im- 
proper, or  decomposing  food,  impure  water,  or  irritating  medi- 
cines, or  by  exposure  to  wet  or  cold,  will  cause  intestinal  catarrh. 
Extensive  burns  will  cause  it.  Chronic  malarial  infection,  and 
chronic  Bright's  disease  may  cause  it.  Predisposing  causes  are 
cirrhosis  of  the  liver,  chronic  valvular  lesions,  and  pulmonary 
emphysema.  It  occurs  at  all  ages.  The  two  great  predisposing 
causes  in  children  are  dentition  and  bad  hygiene  during  the  hot 
months  (Loomis). 

Symptoms. — Diarrhoea  is  its  earliest  and  most  constant  symp- 
tom. Watery  mucus  may  be  discharged  from  the  bowels,  or 
there  may  be  bilious  diarrhoea,  with  pains  and  cramps  in  the 
calves  of  the  legs,  vomiting,  headache,  furred  tongue,  and  green- 
ish stools.  Serous  diarrhoea  is  the  most  common,  and  at  first  the 
dejections  contain  undigested  food.  There  is  pain,  colicky  and 
griping  in  character,  or  it  may  be  dull.  Food  increases  the  pain. 
There  is  a  sense  of  fullness  and  distension  of  the  abdomen,  and 
tenderness  on  pressure.  There  are  flatulence  and  gurgling. 
Nausea  and  vomiting  indicate  that  gastric  catarrh  is  associated 
with  the  intestinal.  There  is  usually  a  mild,  remittent  type  of 
fever,  with  loss  of  appetite,  offensive  breath,  scanty  and  dark 
urine.     Thirst  is  intense  (Loomis). 


ENTERITIS.  177 

Treatment. — Kee]3  the  patient  in  bed.  It  is  safe  to  begin  the 
treatment  in  every  case  of  acute  intestinal  catarrh  by  the  admin- 
istration of  castor  oil.  The  diet  should  consist  of  milk  with 
lime-water.  The  yolk  of  eggs  may  be  given  with  the  milk. 
Prepared  meats  and  light  broths  are  useful.  No  fats  should  be 
allowed,  or  bread  or  any  form  of  starchy  food.  Stimulants  may 
be  given  when  there  is  prostration.  The  abdomen  should  be 
covered  with  warm  fomentations.  Opium  is  the  most  efficient 
agent  and  must  be  given  in  half  grain  doses  every  two  or  three 
hours.  When  the  catarrh  is  of  malarial  origin,  quinine  must  be 
given  in  large  doses.  If  it  is  the  result  of  exposure  to  wet  and 
cold,  diaphoretics  are  indicated.  Chronic  intestinal  catarrh  may 
be  treated  by  astringents;  the  best  are  nitrate  of  silver,  acetate 
of  lead,  and  sulphate  of  copper.  Sponging  the  abdomen  with 
cold  salt  water  is  good  (Loomis). 

PRESCRIPTIONS  FOR  ENTERITIS. 

R     Pulv.  ipecac  comp 3j*. 

Bismuthi  subnitratis ^ij. — M. 

In  pulv.  no.  xxiv.  div. 
Sig. :     A  powder  every  two  to  four  hours  for  a  child  five  years  old. 

— J.  Lewis  Smith. 

R     Pulv.  opii gr.  v. 

Bismuthi  subnitratis.. 31J. — M. 

In  pulv.  no.  xx.  div. 
Sig.  •     A  powder  every  two  to  four  hours  for  a  child  five  years  old. 

— J.  Lewis  Smith. 

R     Liq.  potassii  arsenitis gtt.  L. 

Tincturae  opii .5j . 

Aquae ad  giij, 

Sig.:     A  teaspoonful  before  meals  thrice  daily.     (In  chronic  and 
malarial  form.)  — Bartholow. 

R     Tinct.  opii  deodorat 3j. 

Sig.:     Ten  drops  every  second  or  third  hour,  according  to  age,  to 
the  point  of  tolerance.  — DaCosta. 


178  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

EPILEPSY.     (Falling  Sickness.) 

Is  a  chronic  paroxysmal  affection.  The  paroxysms  are  char- 
acterized by  loss  of  consciousness  and  convulsive  movements  of 
the  muscles.  Convulsions  similar  to  those  of  epilepsy  are  symp- 
tomatic of  different  cerebral  affections,  of  anaemia,  of  injuries  of 
the  head,  and  of  strychnia,  and  are  distinguished  as  epileptiform. 
Epilepsy  is  a  functional  affection.  In  the  majority  of  cases,  the 
loss  of  consciousness  is  as  sudden  as  if  produced  by  a  stunning 
blow  upon  the  head,  and  the  person  falls.  In  a  minority  of 
•cases,  there  is  a  brief  warning  of  the  approaching  fit.  It  is  a 
isense  of  a  "cold  vapor"  emanating  from  some  part  of  the  body 
and  mounting  to  the  head,  and  has  been  called  the  aura  epilep- 
tica  (Flint). 

Cause. — Thirty  per  cent,  of  epileptics  give  a  history  of  an 
inherited  tendency.  Children  of  consanguineous  marriages  are 
often  epileptics.  It  most  frequently  develops  between  the  ages 
of  ten  and  twenty.  Puberty  and  injury  to  the  peripheral  nerves, 
the  skull,  meninges,  and  diseases  of  the  brain  substances  are  ex- 
■citing  causes.  It  may  arise  from  irritation  of  the  genital  organs, 
anomalies  of  menstruation  and  phimosis  (Loomis).  It  is  very 
generally  believed  that  the  immediately  exciting  cause  of  an  epi- 
leptic paroxysm  is  cerebral  anaemia  resulting  from  vaso- motor 
sj)asin.  Venereal  excesses,  and  habits  of  masturbation  have 
been  supposed  to  be  frequent  causes.  Flint  relates  the  case  of  a 
female  patient  who  experienced  the  first  j)aroxysm  during  the 
first  act  of  sexual  congress  after  marriage.  Subsequently,  a 
paroxysm  occurred  at  each  marital  connection,  and  she  became  a 
confirmed  ejDileptic.  It  is  well  known  that  dogs,  cats  and  other 
domestic  animals  are  liable  to  epilepsy  (Flint). 

Symptoms. — (Of  grand  mal.) — The  onset  of  the  paroxysm  is 
often  marked  by  a  loud,  sharp  cry,  and  the  epileptic  falls  heavily. 
Drawing  the  head  toward  one  shoulder  is  sometimes  a  warning 
of  an  epileptic  seizure.  There  is  complete  loss  of  consciousness. 
The  face  is  extremely  pale.  The  pupil  is  invariably  dilated  at 
the  onset  and  does  not  contract  on  exposure  to  bright  light  and 
the  eyes  are  fixed  and  staring,  and  the  muscles  of  the  face,  trunk 
and  extremities  are  rigid.     Opisthotonos  may  occur.     The  face 


EPILEPSY.  179 

soon  becomes  dark  from  asphyxia.  Clonic  convulsions  succeed 
the  tonic  spasms.  The  tongue  is  thrust  between  the  teeth.  The 
teeth  are  sometimes  broken.  The  patient  froths  at  the  mouth, 
and  from  the  injuries  to  the  tongue  the  saliva  is  often  bloody. 
The  body  is  often  bathed  in  a  profuse  sweat.  The  fit  may  ter- 
minate suddenly  or  gradually.  The  patient  has  no  recollection 
of  the  attack,  and  appears  as  if  waked  out  of  a  deep  sleep. 

(Of  petit  mal). — There  is  momentary  loss  of  consciousness, 
the  patient  suddenly  stops;  has  a  fixed  gaze  for  a  second  or  two, 
his  mind  is  confused,  and  then  proceeds  as  if  nothing  had  hap- 
pened. There  may  be  nocturnal  attacks  of  epilepsy.  The  only 
evidence  of  these  attacks  may  be  the  tongue  which  shows  indents 
of  the  teeth,  and  the  pillows  may  be  blood-stained. 

Number  of  Fits. — The  first  fit  may  also  be  the  last.  They 
may  occur  once  a  year,  or  two  or  three  times  in  twenty -four 
hours.  In  women  it  sometimes  seems  to  be  connected  with  the 
menstrual  epoch.  Eighty  per  cent,  of  all  epileptics  are  attacked 
oftener  than  once  a  month. 

Results  of  Epilepsy.— There  may  be  impairment  of  the  mental 
or  physical  condition.  Of  the  mental  faculties,  memory  is  most 
often  impaired.  A  subnormal  temperature  is  very  common 
(Loomis). 

Treatment. — When  an  epileptic  fit  is  once  established  there 
is  little  to  be  done  but  to  prevent  the  patient  from  injuring 
himself.  Try  to  discover  the  cause  and  remove  it.  The  bromides 
are  at  the  pre&ent  time  used  more  than  any  other  remedies.  Cod- 
liver  oil  is  useful.  Nearly  all  the  drugs  of  the  materia  medica 
have  been  tried  (Loomis). 

PRESCRIPTIONS  FOR  EPILEPSY. 

R     Ferri  bromidi gr.  iv. 

Potassii  bromidi 5j . 

Sy rupi  simplicis ^ij . 

Aquae ad oviij- — M. 

Sig. :     A  tablespoonful  twice  daily.     (In  anaemic  patients.) 

— Bartholow. 

R     Extracti  conii  fluidi  (Squibbs)....gij. 
Sig. :     Fifteen  to  sixty  minims  three  times  daily. —  Spitzka. 


180  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Lobelinse  hydrobromat gr.  ^-j. 

Aquse  destillatae Siiss. — M. 

Sig. :     A  teaspoonful  three  or  four  times  a  day.  — Bartholow. 

R     Potassii  bromidi ,,,, 

Sodii  bromidi 

Ammonii  bromidi aa oiij  • 

Potassii  iodidi 

Ammonii  iodidi aa 5iss. 

Ammonii  carbonat  5j- 

Tincturse  calumbse oiss. 

Aquse q.  s.,  ad.  ft Sviij. — M. 

Sig. :     A  teaspoonful  and  a  half  before  each  meal,  and  three  at 
bed  time.  — Brown-Sequard. 

EPISTAXIS. 

Is  nasal  haemorrhage. 

Causes. — The  mucous  membrane  of  the  nose  is  full  of  blood 
vessels,  and  bleeds  easily.  It  may  be  caused  by  ulceration  of  the 
membrane,  by  vascular  tumors,  and  by  mechanical  causes,  as 
valvular  disease  of  the  heart  (Bartholow). 

Symptoms. — There  may  be  a  sense  of  fullness  of  the  head, 
headache,  noises  in  the  ears,  and  vertigo.  The  blood  may  come 
drop  by  drop  from  a  single  nostril,  or  from  the  posterior  nares. 
The  quantity  of  blood  discharged  varies;  it  may  be  an  ounce  or 
even  a  pint  or  quart.  Epistaxis  may  occur  periodically  as  a 
manifestation  of  malaria,  or  take  the  place,  vicariously,  of  the 
menstrual  or  hemorrhoidal  flux  (Bartholow). 

When  the  bleeding  occurs  in  sleep  from  the  posterior  nares,. 
and  is  swallowed,  there  may  be,  if  vomiting  of  the  blood  occurs, 
much  difficulty  in  ascertaining  the  true  source  (Bartholow). 

Treatment. — Small  pellets  of  ice  may  be  introduced  into  the 
nares,  while  a  block  of  ice,  hollowed  out  to  tit  the  nose,  may  be 
put  on  outside.  Simply  pressing  the  nares  together,  to  enable 
the  blood  to  coagulate,  may  often  suffice.  If  pressure  and  cold 
fail,  a  solution  of  tannic  acid,  or  of  .alum,  or  of  acetate  of  lead, 
may  be  thrown  into  the  nares,  and  if  these  fail,  a  solution  of 
Monsel's  salts.  All  other  expedients  failing,  the  posterior  nares 
must  be  plugged  (Bartholow). 


EPISTAXIS ERYSIPELAS.  181 

Small  doses  of  aconite,  given  frequently,  will  often  quickly 
check  the  nose-bleeding  of  children  and  of  plethoric  people. 
Cocaine  may  be  used  locally.  Digitalis  controls  epistaxis,  haem- 
optysis, and  menorrhagia.  A  hot  foot-bath,  with  or  without 
mustard,  is  efficient.  Spinal  hot-water  bag  to  the  cervical  and 
and  ujDper  dorsal  vertebrae  is  serviceable  (Ringer). 

PRESCRIPTIONS  FOR  EPISTAXIS. 

R     Pulv.  alurainis 

Pulv.  acidi  tannici aa 5j- — M. 

Sig. :     To  be  insufflated  into  the  nares  anteriorly  and  posteriorly. 

— Sajous. 

R     Extracti  geranii  mac.  fluidi §j. 

Aquse ,§iij. — M. 

Sig. :     Syringe  the  nostrils,  or  plug  with  cotton  saturated  with  the 
fluid.  — Shoemaker. 

R     Antip  yrin 31J . 

In  capsules  no.  xxiv.  div. 

Sig. :     One,  two  or  three  to  be  taken  as  required.  To  be  used 

with  local  treatment.  — Robinson. 

ERYSIPELAS. 

Is  a  self- limited  febrile  affection,  characterized  by  a  local 
inflammation  of  the  skin,  and  accompanied  by  constitutional 
symptoms.     It  is  contagious  (Bartholow). 

Causes. — The  streptococcus  erysipelatis  is  regarded  as  its 
specific  cause.  It  prevails  in  hospitals  and  epidemics  follow  in 
the  paths  of  armies.  There  are  two  kinds:  idiopathic  and  trau- 
matic. It  is  a  disease,  of  all  ages,  and  occurs  at  all  seasons.  An 
abrasion  of  the  surface  or  wound  is  the  usual  starting  point. 

Symptoms. — -The  initial  symptom  is  a  chill.  Headache 
comes  on  with  the  fever;  and  there  are  nausea,  bilious  vomiting, 
and  entire  loss  of  appetite.  A  sense  of  heat  and  tension  is  felt 
in  the  skin,  which  becomes  red,  cedematous  and  shiny.  The  red 
color  disappears  on  pressure.  The  inflammation  reaches  its 
highest  point  on  the  second  or  third  day,  and  on  the  fourth,  fifth 
or  sixth  day  the  redness  is  fading.  Desquamation  of  the  skin 
takes  place.     The  margin  of  the  redness  is  not  sharply  defined, 


182  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

but  the  swelling  forms  an  abrupt  ridge  (Bartholow).  Trauma- 
tic erysipelas  begins  as  a  bright  red  blush  about  the  point  of 
injury.  Idiopathic  erysipelas  is  most  commonly  facial,  starting 
from  either  the  nose,  eyelid  or  ear  (Loomis). 

Differential  Diagnosis. — Erysipelas  may  be  confounded  with 
erythema  and  urticaria.  Erythema  is  a  superficial  redness  with- 
out inflammation — without  heat  and  swelling — is  without  fever, 
and  does  not  desquamate.  Urticaria  occurs  in  the  form  of. 
wheals  that  itch  a  good  deal  and  disappear  in  a  few  hours 
(Bartholow). 

Treatment. — In  the  more  severe  cases  quinine  combined  with 
belladonna  is  good  treatment. 

R     Quininas  sulphatis gr.  xL. 

Extraoti  belladonna? gr.  iij. — M. 

Ft.  pil.  no.  x. 
Sig. :     One  pill  every  four  hours. 

Tincture  of  the  chloride  of  iron,  in  half- drachm  doses  every 
four  hours,  is  much  commended.  Milk,  eggs,  animal  broths,  and 
when  necessary  stimulants  should  be  given.  The  bowels  and 
kidneys  should  be  kejyt  active. 

Local  Applications. — As  a  rule,  irritating  applications  do  more 
harm  than  good.  Bartholow  has  seen  mercurial  ointment  diluted 
ten  times  with  lard  very  successful ;  or  vaseline  o],  acid  carbolic 
5ss,  or  less,  which  should  be  brushed  over  the  inflamed  area  three 
or  four  times  a  day. 

PRESCRIPTIONS  FOR  ERYSIPELAS. 

R     Tincturse  ferri  chloridi 

Syrupi  simplicis — aa §j . 

A  quae 51J . — M. 

Sig. :     A  teaspoonful  well  diluted  every  two  or  three  hours. 

— Charity  Hospital. 

R     Plumbi  acetatis 3J. 

Tincturse  opii 5J. 

Aquae ad 0.  j. — M. 

Sig. :     Shake  the  bottle  well,  and  wet  cloths  with  the  lotion  and 
apply  to  the  affected  parts.  — Charity  Hospital. 

R     Acetanilidi 5j. 

Ft.  in  no.  xv.  capsules. 
Sig. :     Two  capsules  as  required  for  fever.  — Osier. 


ERYTHEMA ECLAMPSIA.  183 

ERYTHEMA. 

By  this  term  is  meant  simple,  superficial  inflammation  of  the 
corium,  the  most  trifling  of  all  inflammations  of  the  skin,  and 
under  it  we  must  include  roseola,  strophulus  and  pityriasis. 

Symptoms. — There  is  no  fever.  The  local  symptoms  are  not 
severe.  There  is  no  distinct  abrupt  line  of  demarcation  between 
the  healthy  and  diseased  skin.  It  does  not  usually  spread 
rapidly.  The  itching  is  moderate.  The  color  of  the  eruption  is 
usually  pink.     The  causes  are  very  various. 

Erythema  capitis  or  pityriasis  is  usually  a  very  chronic 
affection  and  attacks  the  scalp  and  hairy  parts  of  the  head. 
Chilblain  is  a  form  of  erythema  which  occurs  in  cold  weather, 
and  attacks  the  fingers,  toes,  ears,  nose  and  cheeks. 

PRESCRIPTIONS  FOR  ERYTHEMA. 

R     Zinci  acetatis gr.  ij . 

Aqua?  rosse 3j- 

Ungt.  aquas  rosse 5j*. — M. 

Sig. :     Apply  locally.  — Fox. 

R     Pulveris  camphorse 5ss-j. 

Spiritus  vini  rectificati Sj. 

Sodii  boratis gr.  xl. 

Aquas  rosse oviij. — M. 

Ft.  lotio. 
Sig.:     Apply  locally  several  times  daily.  — Tilbury  Fox. 

R     Pulveris  camphorse 5ss-j. 

Zinci  oxidi oiv. 

Pulveris  amyli 5j . — M. 

Sig.:  Dust  on  lightly  and  do  not  allow  to  cake  upon  the  skin. 

— Bulkley. 

ECLAMPSIA. 

Is  the  term  applied  to  convulsions,  tonic  and  clonic  in  char- 
acter, the  foundation  of  which  is  laid  in  processes  connected  with 
pregnancy,  labor,  and  childbed.  It  occurs  once  in  about  five 
hundred  pregnancies.  The  attack  resembles  that  of  epilepsy, 
the  cry  only  lacking  (Lusk). 


184  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Terminations. — In  favorable  cases,  after  the  expulsion  of  the 
ovum,  the  attacks  cease  or  diminish  in  frequency  and  intensity. 

Prognosis. — Is  always  serious.  The  earlier  the  convulsions 
occur  in  labor  the  more  unfavorable  the  prognosis  (Lusk). 

Treatment. — The  urine  of  pregnant  women  should  be  exam- 
ined occasionally.  If  convulsions  threaten,  the  nervous  irrita- 
bility should  be  held  in  check  by  rectal  injections  of  chloral  and 
bromide  of  potassium  (thirty  grains  each).  From  one -sixth  to 
one -fourth  of  a  grain  of  morphia  should  be  injected  hypodermi- 
cally.  The  lower  bowel  should  be  cleaned  out  by  an  enema, 
and  a  cathartic  should  be  given  by  the  mouth  (Lusk). 

EMBOLISM. 

An  embolus  is  any  solid  body  floating  in  the  blood  current. 
Embolism  is  the  occluding  of  a  vessel  by  an  embolus.  Arteri- 
oles and  capillaries  are  the  usual  seats  of  embolism.  In  general 
an  embolus  is  part  or  all  of  a  dislodged  thrombus. 

Causes. — A  slowing  of  the  blood  current,  or  a  change  in  the 
walls  of  the  vessels,  a  weak  vis-a-tergo,  vegetations  on  the  valves 
of  the  heart,  a  foreign  body  introduced  into  a  vessel,  or  a  frac- 
ture, may  cause  embolism  (Bartholow). 

Symptoms. — Embolic  obstruction  of  a  member  is  announced 
by  a  sudden  and  often  intense  pain  and  a  chill,  with  numbness, 
loss  or  diminution  of  tactile  sense,  coldness,  pallor  of  the  skin, 
and  a  feeling  of  deadness  and  weight,  and  paralysis  of  the  muscles 
(Bartholow). 

Treatment. — Ten  grains  of  the  carbonate  of  ammonia  may  be 
administered  in  a  tablespoonful  of  the  solution  of  the  acetate, 
three  or  four  times  each  day.  Another  remedy  is  the  phosphate 
of  soda,  in  drachm  doses,  three  times  daily  for  many  weeks 
(Bartholow). 

ENURESIS. 

Called,  also,  incontinence  of  urine,  is  a  common  and  trouble- 
some infirmity  of  children.  It  occurs  both  in  boys  and  girls,  but 
is  more  common  in  the  former.  In  many  children  it  dates  back 
to  infancy,  but  in  others  it  begins  at  six  or  seven  years.     There 


ENURESIS.  185 

is  an  increase  in  the  circular  muscular  fibres  at  the  urethral  ori- 
fice which  constitutes  the  sphincter  vesicae,  an  unstripecl  muscle 
and  not  under  the  control  of  the  will.  A  second  sphincter  which 
aids  materially  in  the  retention  of  the  urine  is  formed  by  the 
compressor  urethral,  surrounds  the  whole  membranous  portion, 
and  is  a  striped  muscle  and  therefore  controlled  by  the  will 
(Smith). 

Causes. — In  all  cases  the  urine  should  be  examined.  The 
chief  causes  are:  1.  Too  great  acidity  of  the  urine,  which  will 
irritate  and  cause  the  bladder  to  contract.  2.  Increased  quantity 
of  urine.  This  occurs  from  the  free  use  of  water  or  milk,  or  renal 
disease.  3.  A  vesical  calculus.  This  will  cause  pain  in  passing 
water.  Sound  for  stone.  4.  Excessive  irritability  of  the  muscu- 
lar fibres  of  the  bladder.  This  is  the  most  frequent  cause  of 
enuresis  in  children.  Belladonna  relieves  this  condition.  5. 
Weakness  of  the  muscular  fibres  which  constitute  the  sphincter. 
This  occurs  in  run  down  conditions.  6.  Reflex  action.  This 
may  be  from  phimosis,  stricture  of  the  urethra,  irritation  of  as- 
carides,  fissure  of  the  anus,  onanism,  or  vulvitis.  7.  A  psychical 
cause  to  which  Bartholow  alludes.  The  patient  dreams  that  he 
is  in  a  convenient  place  to  pass  water.  8.  Malformation  of  the 
bladder.     These  are  various  (Smith). 

Prognosis. — Depends  on  the  cause  or  causes. 

Treatment. — For  the  excessive  acidity  of  the  urine,  three  to 
five  drops  of  the  liquor  potassse  should  be  given  three  or  four 
times  daily  in  a  wineglassful  of  water.  In  belladonna  we  rx>s- 
sess  an  agent  which  diminishes  the  functional  activity,  or  inherent 
irritability  of  the  bladder  when  the  latter  is  in  excess.  Five 
drops  of  the  tincture  may  be  given  every  evening,  to  a  child  of 
five  years,  and  the  dose  increased  by  one  drop  every  second  day. 
If  the  enuresis  be  due  to  an  abnormally  large  secretion  of  urine, 
the  liquid  ingesta  in  the  latter  part  of  the  day  should  be  re- 
stricted. If  it  be  due  to  diabetes,  or  chronic  nephritis,  treat 
these  conditions.  If  it  be  due  to  a  vesical  calculus,  lithotomy  is 
indicated.  If  the  cause  of  the  enuresis  be  due  to  irritation  in 
contiguous  parts,  as  the  rectum,  penis  or  vulva,  treat  these  con- 
ditions. If  the  cause  be  due  to  atony  of  the  sphincter,  mix 
vomica  and  ergot  are  indicated. 


186  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  ENURESIS. 

R     Tinturse  belladonna?  Sj  • 

Sig. :  Ten  to  twenty  drops  thrice  daily.  — Ringer. 

R     Acidi  benzoici 3ij. 

Aquse  cinnamomi 3 vj . — M. 

Sig. :     A  tablespoonful  thrice  daily.  — Hartshorne. 

R     Tincturse  ferri  muriatis 3J. 

Decocti  uvae  ursse Svj. — M. 

Sig.:     A  tablespoonful  two  or  three  times  daily.  — Hillis. 

R     Santonini gr.  xvj. 

Olei  ricini oj  • — M. 

Sig. :     One  or  two  teaspoonfuls  before  breakfast  for  two  or  three 
mornings.  — Ringer. 

R     Collodii S  ss. 

Sig.:     Put  a  drop  in  the  meatus  to  seal  it  at  bed  time.     Remove 
with  finger-nail  in  morning.  — Corrigan. 

R     Chloral  hydratis 3J. 

Sy rupi  tolutani 5  iiss. — M. 

Sig.:     A  teaspoonful  thrice  daily.     (For  infantile  incontinence). 

— DaCosta. 

R     Atropinse  sulphatis gr.  j. 

Aquse  destillatae Sj . — M. 

Sig.:  Four  to  eight  drops  in  water.  (For  children).  — Bartholow. 

ENDOMETRITIS. 

Is  an  inflammation  of  the  endometrium.  It  is  acute  and 
chronic.  The  acute  is  a  rare  disease.  The  chronic  is  a  frequent 
disease. 

Causes  of  the  Acute. — This  form  occurs  in  young  girls  after 
acute  fevers,  or  it  may  be  due  to  taking  cold  during  menstrua- 
tion, or  to  an  extension  of  inflammation  from  other  parts,  to 
chronic  catarrh,  or  laceration  of  the  cervix. 

Symptoms. — Leucorrhcea.  The  discharge  is  thick,  and  often 
profuse,  and  resembles  the  white  of  an  egg.  Menorrhagia  may 
be  present.  There  is  a  sense  of  fullness  or  pain  in  the  pelvis 
and  loins. 

Treatment. — Treat  the  cause.  Warm  mucilaginous  injec- 
tions, salines  and  rest  will  give  the  best  results. 


EPIDIDYMITIS.  18  ( 

The  chronic  form  is  divided  into  corporeal  and  cervical. 

Causes. — It  may  follow  the  acute  disease,  or  start  as  a  chronic 
affection  from  specific  or  other  constitutional  causes.  It  may  be 
due  to  lacerated  cervix,  violence  during  coitus,  ill-fitting  pessa- 
ries, etc. 

Symptoms. — Leucorrhoea  is  the  principal  symptom. 

Treatment. — Treat  the  cause.  If  from  lacerated  cervix, 
reduce  the  size  of  the  uterus  by  leeches,  scarifications,  iodine, 
hot-water  injections  and  glycerine  tampons.  If  the  leucorrhoea 
still  persists  operate  for  laceration  of  the  cervix.  If  there  is 
eversion  of  the  cervical  mucous  membrane  scarify  it.  If  there  be 
chronic  catarrh  of  the  cervix,  relieve  the  congestion  by  .local 
measures,  and  use  astringent  applications  to  the  cervical  mucous 
membrane.  If  the  body  of  the  uterus  is  involved,  the  patient  is 
usually  sterile.  In  this  case  dilate  the  uterus  with  tents  left  in 
for  twenty -four  hours.  After  dilatation  wash  the  cavity  with 
carbolic  acid  water  (40  per  cent.)  and  apply  to  the  endometrium 
by  means  of  cotton  on  an  applicator,  solutions  of  corrosive  subli- 
mate, zinc  sulphate,  or  Monsel's  solution  and  glycerine,  repeating 
the  application  every  three  or  four  days.  There  should  be 
absence  from  sexual  intercourse  (Pozzi,  Skene  and  Gooddell.) 

EPIDIDYMITIS. 

Is  an  inflammation  of  the  epididymis.  It  is  the  most 
common  of  all  the  diseases  of  the  testicle.  It  occurs  at  all  ages. 
One  attack  predisposes  to  another.  It  is  often  double.  Fournier 
states  that  epididymitis  occurs  once  for  every  eight  or  nine  cases 
of  gonorrhoea.  In  some  individuals  every  attack  of  gonorrhoea 
is  attended  by  a  swollen  testicle  (Keyes). 

Causes. — Traumatic  violence  and  cold  may  cause  it.  Pro- 
longed sexual  excitement  may  cause  it;  but  urethral  inflamma- 
tion or  irritation  from  gonorrhoea,  stricture,  or  the  passage  of  in- 
struments is  by  far  the  most  active  cause.  It  is  an  extension  of 
the  inflammation  from  the  orifice  of  the  ejaculatory  duct  to  the 
epididymis. 

Symptoms. — First  attacks,  like  first  attacks  of  gonorrhoea, 
are  usually  the  most  severe.     If  there  be  a  gleety  or  gonorrhceal 


188  A    COMPENDIUM    OF    PRACTICAL     MEDICIJSTE. 

discharge,  it  stops  after  the  testicle  begins  to  swell,  but  soon  re- 
turns. There  is  a  feeling  as  if  the  cord  were  being  pulled  upon, 
and  pain  in  the  back.  There  is  frequent  desire  to  urinate,  and 
intense  pain  in  the  testicle,  which  is  swollen.  The  pain  is  of  the 
sickening  variety,  making  patients  feel  faint.  Rest  on  the  back 
with  the  testicle  raised  modifies  the  pain.  Epididymitis  lasts 
about  two  weeks.  Hardness  of  the  epididymus  may  remain  be- 
hind for  months  or  even  years.  Sterility  may  be  produced  if  the 
epididymitis  be  double.  The  testicles  do  not  atrophy.  The  pa- 
tient is  by  no  means  impotent.  He  ejaculates  semen,  but  it 
contains  no  spermatozoa. 

Treatment. — A  suspensory  bandage  should  be  worn  during 
the  existence  of  urethral  disease.  Rest  on  the  back,  elevation  of 
the  testicle,  hot  flax-seed  poultice,  and  a  laxative,  may  be  all  that 
is  necessary.  In  severe  cases,  the  testicle  is  enveloped  from  the 
start  in  a  tobacco  poultice.  The  poultice  is  made  by  mixing  a 
paper  of  any  fine -cut  tobacco  (oj.)  in  about  (sx.)  of  hot  water, 
bringing  the  whole  to  a  boil,  and  then  adding  ground  flax  seed 
until  the  proper  consistence.  The  poultice  is  sprinkled  with 
laudanum  and  placed  upon  the  testicle  as  hot  as  can  be  borne, 
and  covered  with  oiled  silk.  This  poultice  should  be  renewed 
every  eight  hours,  until  the  indurated  epididymus  has  lost  its 
sensitiveness  to  pressure.  Powdered  opium  (si-ii.)  mixed  with 
stramonium  ointment  (Si.)  may  be  used  instead  of  the  tobacco 
poultice.  According  to  Keyes,  the  tobacco  poultice  is  more  ser- 
viceable than  any  other  agent.  Ice  is  not  good.  In  extreme 
pain,  when  the  cord  has  become  strangulated,  ten  to  fifteen 
leeches  above  the  groin  will  often  calm  the  pain  as  by  magic. 
When  pain  is  caused  by  extreme  distention  of  the  tunica  vagin- 
alis with  fluid,  puncture  it,  and  let  out  the  fluid.  Patients 
should  stay  in  bed  about  one  week  in  mild  cases,  and  ten  to 
twelve  days  in  worst  cases.  Tonics  and  cod-liver  oil  do  good 
(Keyes). 


EPISPADIAS EPITHELIOMA EKUCTATIONS.  189 

EPISPADIAS. 

Is  a  fissure  of  the  superior  wall  of  the  urethra,  with  ectopia 
of  the  canal.  It  is  very  rare.  The  urethral  opening  may  be 
upon  the  glans,  or  anywhere  along  the  top  of  the  penis,  as  far 
back  as  its  root.  When  the  membranous  and  prostatic  urethra 
are  involved,  there  is  also  exstrophy  of  the  bladder.  Epispadias 
is  an  arrest  of  development  in  the  upper  wall  of  the  urethra. 

Treatment. — A  cure  cannot  be  promised  from  operative  pro- 
cedure. Operations  which  have  been  undertaken  very  often  fail, 
erections  and  contact  of  urine,  with  smallness  of  flaps,  being  the 
chief  causes.     A  proper  urinal  is  the  best  treatment. 

EPITHELIOMA. 

Is  a  form  of  cutaneous  cancer.  These  tumors  affect  the 
skin  or  mucous  membrane,  and  never  originate  in  any  other 
tissue.  They  infiltrate  the  parts  with  which  they  come  in  con- 
tact, and  do  not,  as  innocent  tumors,  simply  separate  them.  They 
are  the  common  forms  of  cancer  found  in  the  lips,  tongue, 
oesophagus,  rectum,  scrotum,  penis,  clitoris,  os  uteri,  vulva,  etc. 
As  a  local  disease,  epithelioma  may  progress  slowly  for  years, 
and  cause  little  pain,  and  five,  six,  or  even  fifteen  years  may 
elapse  before  advice  is  sought.  The  surface  of  an  epithelial 
cancer  may  be  dry  and  warty,  or  ulcerating;  when  ulcerating 
the  discharge  will  be  a  thin  or  creamy  fluid  (Bryant). 

Treatment. — These  cancers  should  always  be  removed;  and 
the  sooner  this  is  accomplished,  the  better  the  prospects  of  a 
cure. 

ERUCTATIONS.     (  Off  ensi  ve  ) . 

Patients  are  sometimes  greatly  annoyed  by  eructations  of  an 
offensive  gas,  with  the  odor  and  flavor  of  rotten  eggs — a  gas 
consisting  largely  of  sulphurretted  hydrogen.  In  such  cases  the 
urine  is  loaded  with  oxalic  acid,  and  to  correct  the  oxaluria  on 
which  the  eructations  depend,  the  mineral  acids  should  be  given 
in  the  proper  doses  (Ringer). 


190  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ENTERALGIA.     (See  Colic.) 
EPHIDROSIS. 

Called  also  hyperidrosis,  is  an  augmented  sudoriparous 
secretion. 

Causes. — It  may  accompany  any  disease,  and  especially 
phthisis,  as  the  result  of  debility.  It  may  occur  from  excitement 
of  the  body  or  mind.  In  some  cases  there  is  no  apparent  cause. 
The  perspiration  may  be  general  or  local.  It  is  sometimes  lim- 
ited to  one  side  of  the  body  or  face,  when  it  is  supposed  to  result 
from  faulty  innervation  of  the  sympathetic.  The  sweating  is 
often  limited  to  the  soles,  palms,  axillae,  groins  and  genital 
organs.  The  hands  are  moist,  clammy  and  cold  from  rapid 
evaporation  of  the  sweat.  In  the  feet,  the  secretion  is  confined 
by  the  stockings  and  shoes,  and  is  apt  to  inflame  the  soles,  leav- 
ing them  very  tender,  so  that  walking  or  standing  is  painful.  A 
species  of  bacteria  which  grows  and  multiplies  in  this  sweat  is 
the  sonrce  of  the  offensive  odor  (Anderson). 

Treatment. — For  the  general  sweating  from  wasting  diseases, 
tonics,  such  as  quinine,  the  mineral  acids,  strychnia  and  arsenic 
are  recommended.  Atropia  in  doses  of  t~ot  gr.  is  the  most  power- 
ful of  all  remedies  for  general  sweating.  Some  benefit  may  come 
from  sponging  the  body  with  vinegar  and  cold  water.  For  the 
local  sweating,  Dr.  Thin  advises  the  changing  of  the  stockings 
twice  daily.  Dr.  Marten  advises  washing  the  feet  night  and 
morning  with  soap  and  water,  and  sponging  with  the  following 
lotion : 

R     Plumbi  acetatis  3J 

Aceti  destillati §j. 

Spiritus  vini  methylati |ij. 

Aquae ad sxvj . — M. 

Dr.  Simonton  recommends  the  use  of  finely  pulverized  alum. 
The  feet  and  socks  are  thoroughly  dusted  with  the  powder. 
Repeat  this  process  every  two  or  three  days,  and  the  feet  will 
become  hardened.  In  mild  forms,  tannic  acid  5j.  to  Svj.  of  alco- 
hol may  be  rubbed  on  several  times  daily.  Dust  the  feet  thor- 
oughly  with    pulverized    salicylic   acid    before  putting   on  the 


FETOE    OF    AXILLiE FEYEES.  191 

stockings,  and  wash  them  with  permanganate  of  potassium 
(gr.  xxx.-Oj.)  evening  and  morning  and  apply  belladonna  lin- 
iment before  going  to  bed  to  the  feet. 

FETOR  OF  AXILLA,  BREATH  AND  FEET. 

These  are  very  annoying  conditions  and  the  physician  is 
often  consulted  concerning  them.  Permanganate  of  potassium 
is  an  elegant  toilet  preparation  for  destroying  the  odor  of  a  foul 
breath,  the  smell  of  the  axillae,  and  the  fetor  of  the  sweat  of 
the  feet,  and  may  be  used  as  follows: 

R     Potassii  permanganatis gr.  x.-xxx. 

Aquse §viij. — M. 

Sig. :     Apply  locally  frequently.  — Bartholow. 

The  following  formulae  may  be  used  for  the  above  condi- 
tions: 

R     Sodii  bicarbonatis .giij . 

Aqua? §viij. — M. 

Sig.:     Apply  as  a  lotion  frequently.  — Bartholow. 

R     Atropia?  sulphatis..... gr.  iv.-viij. 

Aquse  rosae §ij. — M. 

Sig.:     Apply  to  the  part  with  a  brush,  — Bartholow. 

R     Acidi  salicylici gr.  xLv. 

Pulv.  amyli , gv. 

Pulv.  talc oxxij- — M. 

Sig. :     Dust  over  feet. 

Jfc     Sodii  biboratis gr.  xv. 

Thyraoli gr.  viiss. 

Aquse  destillatse o xij . — M. 

Ft.  sol. 
Sig.:     A  mouth  wash.     (For  fetor  of  breath).  — Magitot. 

FEVERS.      (Classification   of.) 

Fevers  are  distinguished  as  essential  and  symptomatic.  A 
symptomatic  fever  is  one  which  is  secondary  to  some  local  affec- 
tion, such  as  an  acute  inflammation. 

An  essential  fever  is  one  which  is  not  secondary  or  symp- 
tomatic, but  is  primary  or  idiopathic. 

The  essential  fevers  are  as  follows : 


192  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

I.  Febricula,  a  form  of  fever  characterized  by  its  short 
duration  and  mildness. 

II.  Continued  Fevers,  which  are  distinguished  by  the  un- 
broken continuity  of  the  febrile  phenomena,  such  as  typhoid, 
typhus,  relapsing  and  erysipelatous  fevers. 

Ill  Periodical  Fevers,  which  are  distinguished  by  the 
occurrence  of  distinct  paroxysms  of  the  febrile  phenomena,  such 
as  intermittent,  remittent,  typho- malarial  and  yellow  fevers  and 
dengue. 

IV.  Eruptive,  or  exanthematous  fevers,  in  which  an  erup- 
tion on  the  surface  of  the  body  is  a  prominent  feature,  as  in 
small-pox,  scarlet  fever,  measles,  roseola  and  typhus. 

When  the  decline  of  a  fever  is  rapid,  occupying  only  a  few 
hours,  or  a  day  or  two,  the  fever  is  said  to  terminate  by  crisis. 
When  the  decline  is  protracted  the  termination  is  by  lysis.  (Each 
of  the  above  fevers  will  be  considered  in  its  proper  place.) 

Causes  of  Essential  Fevers. — Micro-organisms  are  among  the 
most  important  of  fever-exciting  agents,  and  are  probably  in- 
volved in  the  causation  of  all  the  essential  fevers.  Animal  heat 
is  the  result  of  chemical  processes,  especially  processes  of  oxida- 
tion, which  are  constantly  going  on  within  the  body;  but  it  is 
not  known  in  what  way  the  abnormal  elevation  of  temperature 
is  produced  in  fever  (Flint). 

FISSURE  OF  THE  ANUS. 

Produces  more  misery  than  any  other  local  disease,  and 
renders  the  natural  act  of  defecation  an  agonizing  one. 

Causes. — It  is  usually  caused  by  the  mechanical  splitting  of 
the  orifice  of  the  anus,  from  the  passage  of  a  large  or  indurated 
motion.  It  may  be  due  to  scratching  the  parts  when  highly 
irritable.  Constipation,  high  feeding,  sedentary  habits,  and  want 
of  local  cleanliness  are  the  common  causes. 

Symptoms. — There  is  pain  during  \he  passage  of  the  motion. 
The  motion  may  be  streaked  with  a  line  of  pus  or  blood.  There 
is  an  unnatural  contraction  of  the  sphincter,  and  great  pain  is 
caused  by  attempting  to  introduce  the  finger.  A  careful  exam- 
ination will  often  reveal  the  presence  of  an  ulcer  on  the  verge  of 


FISSUEE    OF    ANUS.  193 

or  within  the  sphincter.  Simple  fissures  are  often  associated 
with  piles  (Bryant). 

Treatment. — Happily  for  patients,  the  treatment  of  the  dis- 
ease is  as  successful  as  it  is  single.  Simple  fissures  are  readily 
treated  by  the  administration  of  a  laxative,  the  local  application 
of  nitrate  of  silver,  or  of  lead  lotion  mixed  with  the  extract  of 
opium,  and  local  cleanliness. 

When  the  parts  are  indolent,  black  wash  may  be  used,  or 
calomel  dusted  over  the  part. 

When  an  ulcer  has  existed  for  some  time  and  has  a  hard 
base,  the  most  efficient  means  of  cure  is  division  of  the  base  of 
the  ulcer  with  the  superficial  fibres  of  the  S23hincter,  or  forcible 
dilatation  of  the  sphincter,  and  its  laceration  with  the  thumbs  in 
the  rectum. 

After=Treatment, — The  bowels  must  be  kept  slightly  loose, 
and  for  this  purpose  the  following  may  be  used: 

JJr     Olei  olivse §j . 

Potassii  carbonatis gr.  xLv. 

Aquse  Mentha?  piperita? oviij. — M. 

Sig. :     One  ounce  three  times  daily. 

PRESCRIPTIONS  FOR  FISSURE  OF  ANUS. 

J{r     Iodoformi 

Acidi  tannici aa 5j  • — M. 

Sig. :     Unfold  or  open  the  fissure,  and  fill  with  and  dust  over  the 
powder.  — Bartholow. 

J{r     Potassii  bromidi oiss. 

Glycerina? Sj  • — M. 

Sig. :     Apply  with  a  brush  locally.  — Ringer. 

J&     Acidi  tannici 5j- 

Gly  cerina? o  ij  • — M. 

Sig.:     Introduce  into  the  rectum  night  and  morning  on  a  tent. 

— Waring. 

|fc     Extracti  hydrastis  fiuidi Sj 

Sig.:     Apply  to  the  fissure.  — Bartholow. 


194  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

FISSURES  OF  THE  NIPPLE, 

Are  excruciatingly  painful,  and  are  capable  of  exciting  even  a 
high  degree  of  fever.  They  occur  with  greatest  frequency  in 
nipples  which  have  been  flattened  by  the  pressure  of  corsets 
(Lush). 

Treatment. — The  nipple  should  be  kept  clean,  and  all  irri- 
tating matter  removed.  When  one  nipple  only  is  affected,  the 
child  need  only  be  applied  to  the  sound  side.  The  healing  pro- 
cess may  be  promoted  by  lead-lotions,  by  a  solution  of  tannin, 
or  by  some  astringent  ointment.  Keep  upon  the  nipple  a  rag 
wetted  with  Goulard's  extract,  a  teaspoonful  to  a  tumbler  of 
water.  If  the  child  be  troubled  with  sprue,  its  mouth  and  the 
nipples  of  the  mother  must  be  washed  with  a  solution  of 
boracic  acid. 

PRESCRIPTIONS  FOR  FISSURE  OF  THE  NIPPLES. 

|fc     Cocaini  muriatis gr.  x. 

Aquas  destillata? 5ij- — M. 

Sig. :  Apply  with  a  brush  to  the  fissure  half  an  hour  before 
nursing,  and  wash  well  with  warm  water  just  before  nursing. 

— L.  Starr. 

jfc     Plumbi  nitratis gr.  iv-x. 

Gly  cerinse 3J . — M. 

Sig. :  Apply  after  nursing,  and  wash  the  nipple  carefully  before 
the  next  nursing.  — Bartholow. 

JJr     Acidi  carbolici gr.  xxiv. 

Aquae Sj. — M. 

Ft.  lotio. 
Sig.:     Apply  several  times  daily  to  the  nipples.  — Parvin. 

JJr     Acidi  boracici gr.  xx. 

Mucilag.  acacias  5J- — M. 

Sig.:  Use  a  nipple  shield,  and,  after  nursing,  dry  the  nipple  well 
with  absorbent  cotton  and  apply  the  lotion  with  a  camel's  hair  brush. 
Should  this  fail,  touch  the  fissure  with  a  point  of  nitrate  silver  every 
other  day.  — Starr. 

Jfc     Tincturse  benzoini  composite §ss. 

Glycerini Sss. — M. 

Sig. :     Appty  to  affected  parts.  — Stille. 


FISTUL.E.  195 

FISTULA. 

Is  an  unnatural  communication  between  a  normal  cavity  or 
canal  and  the  outside  of  the  body  or  with  a  second  body  or  canal. 
According  to  their  situation,  they  are  named  vesico-vaginal,  and 
recto-vaginal  in  women,  and  recto-vesical  in  men,  gastric,  biliary, 
faecal,  anal,  salivary  and  urinary  fistulas. 

Causes. — They  may  be  congenital  or  acquired.  The  acquired 
fistulae  are  either  due  primarily  to  some  suppurative  or  ulcerative 
process  or  to  mechanical  violence,  operative  or  otherwise,  and 
subsequently  to  a  want  of  repair.  The  fistula  may  be  a  short  or 
a  long  narrow  tract.  When  the  fistula  is  of  recent  origin,  the 
walls  will  be  soft;  when  old,  hard  (Bryant). 

Treatment. — In  a  general  way,  it  may  be  asserted  that  so 
long  as  the  cause  of  a  fistula  exists  repair  cannot  go  on;  so  that 
in  urinary  fistula,  when  stricture  is  the  cause,  the  stricture  must 
be  treated  before  the  fistula.  When  the  cause  of  the  fistula  has 
been  cured  or  removed,  then  the  fistula  itself  may  be  treated, 
and  various  are  the  means  that  can  be  employed  for  the  same. 
Vaginal  and  rectal  fistulae  usually  require  plastic  operations. 
The  whole  margin  of  the  fistula  must  be  pared  with  nicety  and 
accuracy,  and  the  raw  surfaces  brought  into  ap23osition.  The 
constitutional  treatment  resolves  itself  into  tonics,  good  food  and 
fresh  air. 

PRESCRIPTIONS  FOR  FISTUL4E. 

Jfc     Cupri  sulphatis gr.  ii.-iv. 

Aquae siv. — M. 

Sig. :     Inject  once  a  day.  — Sir  A.  Cooper. 

J$r     Argenti  nitratis gr.  ij. 

Aqua?  destillatffi 5 viij . — M. 

Sig.:     Inject  once  a  day.     (Fistula  in  ano.)  — Druitt. 

|fc     Tinctura?  iodini  gj. 

Sig.:     Inject  once  daily.  — Waring. 

J&     Extraeti  sanguinarijc  fluidi sij. 

Sig.:     Inject  a  sufficient  quantity  to  fill  and  distend  the  fistula, 

—Phillips. 


196  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

FLATULENCE. 

The  gas  in  the  intestinal  canal  may  he  merely  air  which  is 
swallowed;  or  it  may  result  from  fermentation  or  decomposition 
of  food.  It  causes  a  disgust  for  eating,  a  feeling  of  distention, 
and  sometimes  actual  pain,  shortened  breathing,  palpitation  of 
the  heart,  eructation  or  belching  of  gas  with  or  without  an  odor 
(DaCosta). 

Treatment. — According  to  Wood,  the  remedy  most  effective 
to  remove  and  permanently  cure  a  disposition  to  the  accumula- 
tion of  flatus  in  the  bowels  is  an  infusion  made  with  half  an 
ounce  of  calumba,  half  an  ounce  of  ginger,  a  drachm  of  senna, 
and  a  pint  of  boiling  water,  and  given  in  the  dose  of  a  wine- 
glassful  three  times  a  day. 

PRESCRIPTIONS  FOR  FLATULENCE. 

Ji     Aquse  camphorse siij. 

Tincturse  lavandulse  comp §j. — M. 

Sig. :     A  tablespoonful  every  hour  or  two.     (For  hysterical  flatu- 
lence and  flatulent  colic  occurring  at  climacteric.)  — Bartholow. 

{&     Spiritus  chloroformi 

Tinctune  cardamonii  comp...aa...3ij. 
Sig.:     A  teaspoonful  every  half  hour  in  water.  — Bartholow. 

Jfc     Misturse  asafoetidae 5iij. 

Sig.:     A  teaspoonful  when  necessary.     (For  the  flatulent  colic  of 
infants.)  — Bartholow. 

J&     Spiritus  setheris  compositi ^ij. 

Aquse  camphors? 5ij . — M. 

Sig.:     Two  teaspoonfuls  to  expel  flatus  from  stomach. 

—  Bartholow. 

|fc     Spiritus  setheris  comp 

Tincturse  ammonii  valerian... aa.. .5]. — M. 
Sig  :     A  teaspoonful  in   water    every  fifteen    minutes    until    re- 
lieved.    (For  hysterical  flatulence  and  globus  hystericus.) 

— Bartholow. 

{fc     Olei  terebinthinae oj. 

Sig.:     Three  to  five  drops  on  a  lump  of  sugar. — Bartholow. 


FEECKLES.  197 

FRECKLES. 

Called  also  lentigo,  is  the  most  circumscribed  form  of  pig- 
mentation, and  the  deformity  to  which  in  well  marked  cases  it 
gives  rise,  is  so  well  known  as  to  require  no  description.  It  is 
most  apt  to  appear  in  persons  with  delicate  skins,  and  in  those 
who  have  fair  complexions,  but  above  all  in  red-haired  people. 
It  is  always  aggravated  by  exposure  to  the  sun,  hence  it  is  met 
with  on  the  face,  neck  and  hands  more  particularly,  and  is  most 
23ronounced  during  the  summer  months. 

Treatment. — Avoid  unnecessary  exposure  to  the  sun.  Ac- 
cording to  Bartholow  the  following  lotion  is  useful  in  freckles, 
sunburn  and  tan  : 

{&•     Potassii  carbonatis giij. 

Sodii  chloridi 3ij. 

Aquse  rosse 5viij . 

Aquse  aurantii  flor §ij. — M. 

Sig. :     Apply  to  part. 

Yfc     Liquoris  potassse gj. 

Aquas  rosse §ij- — M. 

Ft.  lotio. 
Sig.:     Face-wash.     (In  tan  and  freckles.)  — Todd. 

J£     Hydrargyri  chloridi  corr gr.  j. 

Zinci  oxidi 31J . 

Zinci  carbonatis ,...§ss. 

Glycerinse  31J. 

Aquas  rosse 5 viij . — M. 

Ft.  lotio. 
Sig.:     Apply  with  a  sponge.     (In  freckles  and  sunburn). —  Fox. 

JJr     Lactis  recenti* gxiiss. 

Glycerinse gviiss. 

Acidi  hydrochlorici ZTT.Lxxv 

Ammonii  muriatis   3J. — M. 

Ft.  lotio. 
Sig.:     Apply   morning   and    evening  with    camel's   hair   brush. 
(In  tan  and  freckles).  — Monin. 


198  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

FROST=BITE. 

When  concentrated  cold  is  apjDlied  for  a  period  sufficient  to 
arrest  the  circulation  in  a  part,  a  frost-bite  is  the  result.  The 
first  effect  of  cold  upon  a  part  is  a  sense  of  numbness  and  weight 
and  a  feeling  of  tingling.  If  the  cold  continue,  the  part  will 
become  stiff  and  at  last  insensible,  feeling  dead.  The  frozen 
part  is  white  and  waxy.  The  constitutional  effects  of  cold  are 
at  first  stimulating,  and  subsequently  depressing. 

Treatment.- — Sudden  alteration  of  temperature  is  most  in- 
jurious. The  aim  of  the  surgeon  should  be  to  recall  the 
affected  parts  gradually  to  their  normal  condition  by  gentle 
friction  in  the  course  of  the  veins  with  furs  or  flannels.  Stimu- 
lants should  be  administered  internally.  Friction  with  snow  or 
ice-water  is  most  useful.  On  reaction  the  parts  may  be  raised, 
and  warm  milk  with  a  little  brandy  given.  Should  reaction  be 
too  severe,  it  must  be  checked  by  lead  or  spirit  lotions. 

When  gangrene  follows,  carbolic  acid  and  oil  are  probably 
the  best  ajjplications. 

If  a  whole  foot  be  frozen,  amputation  may  be  called  for,  the 
surgeon  always  waiting  until  the  line  of  demarcation  is  formed. 

PRESCRIPTIONS  FOR  FROST=BITE. 

R      Acidi  carbolici  3J. 

Tinct.  iodinii 3ij . 

Acidi  tanici £i j . 

Cerati  simplicis  |iv. — M. 

Ft.  ungt. 
Sig. :     Apply  locally.  — Bartholow. 

R      Linimenti  camphorse. 

Linimenti  saponis  comp 

Olei  caj  uputi aa §j . — M. 

Ft.  linimentum. 
Sig.:     Apply  to  the  unbroken  skin.  — Brande. 

R     Camphorse 3.j . 

Olei  cajuput  gij. 

JEtheris 3j. — M. 

Ft.  linimentum. 
Sig.:     Apply  locally  to  the  unbroken  skin.  — Tortual. 


FURUNCLE — FITS FELON FAINTING.  199 

FURUNCLE.     (See  Boil.) 

FALLING  SICKNESS.     (See  Epilepsy.) 

FITS.     (See  Convulsions.) 

FLOODING.     (See  Menorrhagia.) 

FELON. 

Called  also  paronychia,  or  whitlow,  is  an  abscess  of  the 
thumb  or  fingers.  The  superficial  whitlow  or  felon  consists  of 
inflammation  of  the  surface  of  the  skin  of  the  last  phalanx.  It 
is  generally  seated  immediately  around  and  beneath  the  nail.  It 
is  attended  with  great  pain  and  throbbing,  and  suppuration  at 
the  root  of  the  nail,  which  may  come  off. 

The  deep-seated  variety  is  attended  with  a  severe  throbbing 
pain,  great  tenderness,  tense  and  resisting  swelling,  and  great 
constitutional  disturbance.  The  inflammation  usually  begins  in 
or  beneath  the  j)eriosteuin.  It  may  lead  to  suppuration,  and 
leave  the  fingers  stiff  and  useless. 

Treatment. — If  purgatives  and  fomentations  do  not  speedily 
bring  relief,  the  finger  must  be  freely  laid  open.  The  knife 
should  be  carried  deep  enough  to  feel  the  resistance  of  the  bone 
or  tendon.  A  strong  solution  of  nitrate  of  silver  in  nitric  ether 
applied  over  the  part  may  abort  the  affection,  if  at  the  beginning 
(Bartholow). 

FAINTINGS. 

Treatment. — In  the  threatened  fainting,  it  is  a  good  plan  to 
direct  the  patient,  whilst  sitting  down,  to  lean  forward,  and  place 
the  head  between  the  legs  as  low  down  as  possible,  so  that  the 
blood  may  gravitate  to  the  brain.  Brandy  or  wine  are  the  best 
remedies,  when  the  heart  is  suddenly  enfeebled  from  fright,  loss 
of  blood,  accidents  or  other  causes.  Salts  of  ammonium,  applied 
to  the  nose,  and  breathed  into  the  air-passages,  are  coimnoiilv 
used  in  fainting.  Cold  water  smartly  sprinkled  on  the  face  of  a 
swooning  person  is  a  familiar  way  of  restoring  consciousness 
(Ringer). 


200  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

FATIGUE. 

Treatment. — The  sitz-bath  greatly  relieves  fatigue  and 
soothes  an  irritable,  restless  state  of  the  nervous  system.  A 
pedestrian,  after  great  exertion  and  fatigue,  will  find  it  an  agree- 
able restorative,  preventing  stiffness  and  aching  muscles,  to  strip 
and  wrap  himself  in  a  dripping  wet  cold  sheet,  well  rubbing 
himself  afterwards;  but  if  stiffness  still  remains,  a  few  drops  of 
tincture  of  arnica  taken  internally  will  remove  it.  Tea  and 
coffee  are  especially  useful  in  a  fatigued  state  of  the  system,  and 
under  ordinary  circumstances  are  preferable  in  this  respect  to 
alcoholic  drinks  (Ringer). 

FLUSHING  HEATS. 

The  distressing  symptoms  occurring  during  the  "change 
of  life "  are  very  various.  There  are  heats  and  flushings, 
followed  by  free  perspiration,  and  prostration  is  sometimes 
extreme.  These  symptoms  will  generally  give  way  to  bro- 
mide of  potassium.  Eucalyptol  is  given  in  the  various  symp- 
toms connected  with  the  change  of  life,  as  flatulence,  palpitation 
and  flushings.  A  woman,  from  the  sudden  arrest  of  menstrua- 
tion, or  through  depraved  health,  or  nervous  depression,  or  more 
frequently  at  the  "change  of  life,"  suffers  from  frequent  attacks 
of  flushings  or  heats,  starting  from  various  parts,  as  the  face, 
epigastrium,  etc.,  and  thence  spreading  over  the  greater  part  of 
the  body.  These  heats  may  last  a  few  minutes  only,  or  an  hour 
or  more,  and  may  be  repeated  many  times  a  day.  The  least  ex- 
ertion or  excitement  may  bring  on  these  heats,  and  such  a 
patient  generally  complains  of  cold  feet,  and  sometimes  of  cold 
hands.  The  flushings  are  occasionally  abruptly  limited,  reach- 
ing to  the  thighs,  knees  or  elbows,  and  while  all  the  parts  above 
these  feel  burning  hot,  the  parts  below  feel  icy  cold.  In  many 
of  these  cases  palpitation  or  flutterings  at  the  heart  occur  on  the 
slightest  excitement. 

Nitrite  of  amyl  will  prevent  or  greatly  lessen  these  flush- 
ings or  heats,  and  should  be  given  in  doses  of  a  tenth  to  a  sixth 
of  a  minim,  in  thirty  times  its  volume  of  rectified  spirit,  every 


FRACTURES.  201 

three  hours,  with  an  additional  dose  as  soon  as  the  flush  begins. 
Both  men  and  women,  but  chiefly  women  about  forty  or  fifty 
years  of  age,  are  apt  to  complain  of  a  sensation  of  great  weight 
and  heat  on  the  top  of  the  head,  with  frequent  flushings  of  the 
face,  suffusion  of  the  eyes,  hot  and  cold  perspirations,  and  some- 
times shooting  pains  passing  up  the  back  of  the  head  In  these 
cases,  a  drop  of  laudanum,  with  two  of  the  tincture  of  mix 
vomica,  repeated  three  or  four  times  a  day,  will  give  great  re- 
lief. Valerianate  of  zinc,  given  in  three  to  five  grain  doses  in  a 
coated  pill,  will  usually  remove  the  flushings  of  the  face,  hot  and 
cold  perspirations,  fluttering  at  the  heart,  and  heat,  and  weight 
on  top  of  the  head  (Ringer). 

FRACTURES. 

A  fracture  is  a  solution  of  continuity  of  bone,  while  dislo- 
cation is  a  solution  of  contiguity. 

Kinds, — 1.  Complete.  2.  Incomplete.  3.  Epiphyseal  sep- 
aration. A  complete  fracture  is  where  division  completely 
traverses  the  thickness  of  the  bone.'  An  incomplete  fracture  is 
where  division  does  not  completely  traverse  the  thickness  of  the 
bone.  The  epiphyseal  is  where  the  epiphysis  becomes  separated 
from  the  bone  or  diaphesis. 

Complete  fractures  may  be  of  the  following  kinds:  1. 
Simple.  2.  Compound.  3.  Comminuted.  4.  Complicated.  5. 
Impacted.     6.  Multiple.     7.  Gunshot. 

1.  Simple  is  where  the  bone  is  broken  in  one  place  only, 
and  with  no  communicatioD  with  the  external  air.  2.  Comrjound 
is  where  there  is  communication  with  the  external  air.  3.  Com- 
minuted is  where  there  are  a  great  many  small  pieces  of  bone. 
4.  Complicated  is  where  the  fracture  is  associated  with  the  main 
vessels,  nerves,  veins,  or  some  internal  organs.  5.  Impacted  is 
where  compact  tissue  is  driven  into  the  cancellous  tissue.  6. 
Multiple  is  where  the  bone  is  broken  into  several  pieces.  7. 
Gunshot  is  where  the  fracture  is  the  result  of  the  explosion  of 
fire-arms.  Any  fracture  may  be  oblique,  transverse,  longitudinal 
or  dentated.  Incomplete  fractures  are  the  following:  1.  Green - 
stick.     2.  Partial.     3.  Fissured.     4.  Punctured.    5.  Stellate.     6. 


202  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Spiral.  7.  Gunshot.  Epiphyseal  separations  occur  in  early  life, 
under  twenty  years.  The  causes,  symptoms  and  treatment  are 
the  same  as  fractures.  Most  fractures  occur  between  the  ages  of 
twenty-five  and  sixty.  More  common  in  men  than  in  women. 
More  occur  in  winter  than  in  summer.  The  clavicle  and  radius 
are  more  often  broken  than  any  other  bones. 

Symptoms. — 1.  False  point  of  motion.  2.  Rotary  displace- 
ment. 3.  Angular  deviation  from  the  normal  axis.  4.  Crepitus. 
5.  Tenderness  on  pressure.  6.  Unnatural  mobility.  7.  Retrac- 
tion of  muscles.  8.  Ecchymosis  and  swelling.  9.  Shortening. 
Crepitus  is  the  most  important  sign,  but  may  be  absent  some- 
times, because  of  something  between  the  fragments. 

General  Management. — Give  every  fracture  proper  and  dili- 
gent attention.  When  called  to  see  a  case:  1.  Do  not  move  the 
patient  to  a  vehicle  and  clo  not  set  him  upright.  2.  Put  on  a 
temporary  splint  at  once  and  carry  home  in  a  horizontal  position. 
3.  Put  patient  on  a  hard  mattress  and  not  on  a  feather  bed.  4. 
Cut  off  the  trousers,  boot  and  shoe,  and  do  not  pull  them  off. 
5.  Inspect  the  fracture,  have  a  good  assistant  to  make  strong  ex- 
tension of  the  limb  in  the  long  axis,  and  then  he  may  raise  the 
limb.  You  may  then  inspect  it  to  a  better  advantage.  6.  Make 
extension.  Get  the  great  toe  in  a  line  with  the  inner  margin  of 
the  inner  malleolus  and  patella  and  then  have  the  foot  at  right 
angles  with  the  limb.  Give  a  hypodermic  injection  of  morphine 
to  relax  muscles.  You  may  divide  every  tendon  in  case  you 
can  not  keep  the  muscles  from  contracting. 

Diagnosis. — Three  signs  are  sure:  1.  Mobility.  2.  Crepitus. 
3.  Displacement.  In  cases  of  doubt,  give  an  anaesthetic.  Treat 
any  injury  as  you  would  a  fracture  when  there  is  doubt  as  to 
what  it  is.  (For  the  treatment  of  special  fractures,  see  works 
on  surgery.) 

GALACTORRHEA. 

Is  a  constant  dribbling  of  milk  from  the  nipple.  It  is  an 
affection  which  may  continue  long  after  lactation  has  been  sus- 
pended. It  acts  like  any  other  profuse  discharge  in  exhausting 
the  strength  and  producing  a  wasting  of  the  tissues. 


GALACTORRHEA — GALL- STONES GANGRENE.  203 

Treatment. — Consists  in  interrupting  lactation,  in  compres- 
sion of  the  breasts  with  bandages,  and  tonics  to  repair  the  gen- 
eral health.  Of  special  measures,  saline  laxatives  and  the  inter- 
nal administration  of  iodide   of  potassium  are   of  most  repute 

(Lusk). 

PRESCRIPTIONS  FOR  GALACTORRHEA. 

J&-     Olei  camphorati §vj. 

Sig. :     Apply  externally  to  breasts.  — Waring. 

Jfr     Potassii  iodidi |j. 

Aquas 5J . — M. 

Sig.:     Twenty-five  to  thirty  drops  in  water,  once  or  twice  daily. 

— Roussell. 

Ifr     Atropines  sulphatis gr.  iv. 

Aquas  rosas §j .-— M. 

Sig. :     Apply  on  lint  around  the  breasts,  and  remove  when  the 
throat  becomes  dry.  — Bartholow. 

GALL=STONES.     (See  Biliary  Calculi.) 
GANGRENE. 

Called  also  mortification,  is  the  death  of  any  part  of  the 
body  in  consequence  of  disease  or  injury.  It  is  divided  into 
acute  and  chronic.  The  acute  is  known  as  moist  gangrene.  The 
chronic,  as  dry  or  senile  gangiene. 

Causes.  —  Predisposing  and  exciting.  The  predisposing 
causes  are:  Defective  nervous  power,  as  in  palsied  limbs,  or 
division  of  large  nerve  trunks;  general  debility  from  poor  food 
and  improper  nourishment;  use  of  alcoholic  drinks;  atheroma- 
tous changes  in  the  arteries  of  old  people.  The  exciting  causes 
are  produced  by  whatever  interferes  with  or  arrests  the  circula- 
tion of  a  part.  The  arterial  blood  to  a  part  may  be  cut  off  by 
accident,  by  ligature,  by  thrombosis  or  embolism  of  the  arteries. 
The  circulation  through  a  part  may  be  obstructed  by  the  growth 
of  a  tumor  or  by  the  formation  of  bed-sores.  Extreme  weakness 
of  the  heart's  action  may  produce  gangrene,  or  whatever  de- 
stroys the  cells  of  a  part,  as  injuries,  chemical  agents,  prolonged 
use  of  mercury  or  excessive  heat  or  cold  (Bryant). 


204  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — Are  local  and  constitutional.  Locally,  at  the 
beginning,  the  pain  and  tenderness  of  the  part  become  most 
acute;  it  is  of  a  severe,  burning  character;  the  discoloration  is  of 
a  vivid-red  color;  the  local  heat  is  increased.  The  constitu- 
tional symptoms  are  of  a  low  typhoid  cast.  There  is  a  profuse 
perspiration.  "When  the  part  is  dead,  the  pain  and  tenderness 
cease:  it  becomes  cold,  the  bright  redness  disappears,  and  large 
blisters  form  which  burst  and  leave  a  greenish  discoloration 
beneath.  The  limb  becomes  greatly  swollen,  soft  and  boggy;  a 
sickening  fetid  smell  is  exhaled.  When  the  progress  of  the  dis- 
ease is  arrested,  the  line  of  demarcation  forms  which  separates 
the  living  from  the  dead  tissue. 

Treatment. — To  avert  the  threatened  gangrene  the  patient,  if 
young  and  robust,  with  a  full  hard  pulse,  should  be  purged.  If 
there  is  a  great  deal  of  inflammation,  incisions  should  be  made 
into  the  part,  and  lead  water  with  laudanum  applied.  The  timely 
use  of  a  blister  over  the  entire  surface  will  sometimes  bring 
about  healthy  action,  and  set  aside  the  tendency  to  gangrene. 
Iron,  quinine,  strychnine,  stimulants  and  nutritious  diet 
should  be  prescribed.  The  limb  should  be  put  in  an  aseptic 
condition  by  washing  it  with  ToVo  solution  of  corrosive  sublimate, 
and  then  applying  cotton  wool  and  a  bandage.  It  should  be 
elevated  and  at  rest.  To  allay  fetor,  permanganate  of  potassium, 
carbolic  acid  and  the  chlorides  must  be  resorted  to.  Cleanliness 
and  thorough  ventilation  of  the  apartments  must  be  insisted 
upon  (Bryant). 

CHRONIC,  DRY  OR  SENILE  GANGRENE. 

Causes. — Diseased  state  of  the  arteries,  weak  heart  and  con- 
sequent feeble  circulation  may  cause  it.  In  many  cases  it  begins 
without  any  apparent  exciting  cause.  In  old  people,  diabetes  is 
a  fertile  cause  of  gangrene  of  the  toes  and  feet. 

Symptoms. — There  will  be  a  sensation  of  weight  in  the  part, 
with  coldness,  numbness,  itching  and  tingling  of  the  feet,  and 
cramps  of  the  calves  are  complained  of.  On  examination,  a 
small  dark  or  purplish  spot  will  be  found  on  the  inside  of  one  of 
the  toes,  not  larger  than  a  mustard  seed.  This  is  followed  by  a 
vesicle  which  exposes  a  black  surface  on  bursting.     This  grad- 


GANGREXE.  205 

u ally  spreads  until  the  whole  foot  is  involved.  It  may  begin  on 
several  toes  at  the  same  time,  or  it  may  show  itself  on  the  instep 
or  heel.  The  part  destroyed  becomes  black,  dry,  withered,  cold 
and  insensible. 

Treatment. — As  soon  as  the  line  of  demarcation  forms  be- 
tween the  dead  and  living  tissue,  the  health  of  the  patient  im- 
proves. Tonics  with  stimulants  should  be  given  early.  Locally 
cotton  wool  in  thick  layers  around  the  foot  and  limb  must  be 
used. 

Question  of  Amputation. — If  the  gangrene  is  the  result  of  a 
severe  injury,  and  it  is  rapidly  spreading,  or  if  it  arises  from  a 
wound  or  ligature  of  an  artery,  the  rule  is  to  amputate  at  once. 
In  the  above  cases,  do  not  wait  for  the  line  of  demarcation  to 
form. 

In  chronic  gangrene,  due  to  diabetes,  or  ergotism,  wait  for 
the  line  of  demarcation  to  form.  In  cases  of  frost-bite,  or  burn, 
or  disease  of  the  arteries,  wait  for  the  line  of  demarcation 
(Bryant). 

PRESCRIPTIONS  FOR  GANGRENE. 

R     Brominii  §j. 

Sig. :     Apply  to  the  slough  with  a  glass  rod.  — Bartholow. 

R     Cerati  resinas  comp 5J. 

Extracti  opii  aquos  3j. 

Olei  olivre  gij. — M. 

Ft.  ungt. 

Sig. :     Apply  locally  after  the  slough  has  separated. 

— Witherstine. 
R     Liqour  hydrogenii  peroxidi  siv. 

Sig.:     Apply  locally,  pure  or  diluted. 

R     Acidi  nitrici  5J. 

Sig.:     Apply  to  the  ulcer  with  a  glass  rod  until   it  is   converted 
into  a  firm,  dry  mass.  — Waring. 

R     Sodii  sulphitis oj-ij- 

Aquas  5x. — M. 

Ft.  lotio. 
Sig.:     Use  as  a  lotion,  or  apply  on  compresses.  — Waring. 

R     Pulv.  acidi  salicylici §j. 

Sig.:     Use  locally  as  a  dusting  powder.     (To  destroy  fetor  and 
change  morbid  action).  — Bartholow. 


206  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

GASTRALGIA. 

Is  a  painful  state  of  the  sensory  nerves  of  the  stomach, 
induced  by  irritation,  and  without  fever. 

Causes. — The  neurotic  temperament,  malaria,  and  the  abuse 
of  tea  and  coffee  have  no  little  influence  in  causing  the  disease 
(Bartholow).  Strawberries,  or  honey,  or  other  ingesta,  or  cold 
may  bring  on  an  attack  (Flint). 

Symptoms. — Severe  paroxysmal  pain  in  the  epigastrium, 
radiating  upward  over  the  chest  and  downward  through  the  ab- 
domen, and  through  to  the  back  is  the  most  characteristic 
symptom. 

The  pain  is  diminished  by  pressure,  and  the  patient  instinct- 
ively lies  or  presses  firmly  on  the  abdomen.  In  the  severest 
cases  the  pain  is  excessive.  The  duration  of  the  attacks  may  be 
a  few  hours,  or  a  day  or  two,  or  a  month  with  intermissions. 
Usually  the  attacks  are  of  short  duration,  and  terminate  with 
eructations  of  gas  and  with  vomiting.  Persons  of  sedentary 
habits  are  more  likely  to  be  affected  than  those  engaged  in  active 
pursuits  (Bartholow). 

Treatment. — During  a  paroxysm,  the  first  point  is  the  relief 
of  pain  by  the  hypodermic  injection  of  morphine..  The  pain 
and  also  the  nausea  and  vomiting  may  be  arrested  by  creosote  or 
carbolic  acid.  Equal  parts  of  tincture  of  iodine  and  carbolic 
acid,  of  which  a  drop  may  be  given  every  hour  in  a  little  cold 
water,  will  often  stop  the  pain  and  vomiting. 

The  paroxysms  may  be  relieved  by  one  drop  of  Fowler's  so- 
lution and  two  to  five  drops  of  tincture  of  opium.  The  long 
continued  use  of  arsenic  in  a  small  dose — one  drop  ter  in  die  of 
Fowler's  solution — is  more  effective  according  to  Bartholow's  ex- 
perience than  any  remedy  mentioned. 

Salicylic  acid  is  sometimes  serviceable  for  intermittent  cases. 
When  attacks  of  gastralgia  are  due  to  indigestible  food,  the  first 
duty  is  to  empty  the  stomach.  Excellent  results  are  often  ob- 
■  tained  from  the  use  of  muriatic  acid,  combined  with  tincture  of 
mix  vomica.  The  diet  should  be  regulated.  A  sinapism  and 
fomentations  to  the  epigastrium  are  useful  as  aids.  Mild  cathar- 
tics may  be  given  (Bartholow).     Bismuth  in  doses  from  a  scruple 


GASTBALGIA GASTRIC  ULCER.  207 

to  a  drachm  three  or  four  times  a  day,  lias  been  found  to  be 
curative,  according  to  Flint.  The  constant  current  in  the  hands 
of  Leube,  Beard,  and  Rockwell  has  proved  efficacious.  Change 
of  habits  from  those  of  sedentary  to  active  life  is  of  the  first 
importance. 

Alcoholic  stimulants  in  moderation  with  meals  may  be  ad- 
vised for  a  time  (Flint). 

PRESCRIPTIONS  FOR  GASTRALQIA. 

R     Tincturse  conii  3J. 

Tincturre  Valerianae 

Tincturse  opii  camphoratae 

Aquse  lauro-carasi — aa gij . — M. 

Sig. :     Seven  drops  in  a  little  milk  when  the  pain  appears. 

— Monin. 

R     Extracti  coca?  fluidi 3J. 

Syrupi  aurantii  flor 3v. 

Aquas ad gij. — M. 

Sig.:     A  teaspoonful  every  hour  till  relieved.  — D'Ardenne. 

R     Liq.  chloroformi  aq.  sat 3xv. 

Aquse  aurantii  flor 3xiv. 

Tincturse  anisi  stellati 3j . — M. 

Sig. :     A  teaspoonful  every  quarter  of  an  hour. 

— Dujardin-Beaumetz. 

R     Liquoris  potassii  arsenitis |j. 

Sig. :     One  drop  in  water  three  times  daily  continued  for  months. 

— Bartholow. 

GASTRIC  ULCER. 

Causes. — Ulcer  of  the  stomach  is  a  comparatively  common 
disease,  and  is  found  to  exist  in  five  per  cent,  of  the  deaths  from 
all  causes.  It  occurs  in  females  oftener  than  in  males.  The  lia- 
bility to  it  is  greatest  between  the  ages  of  fourteen  and  thirty, 
although  no  age  is  exempt;  it  has  been  found  in  the  new  born 
babe  and  in  the  octogenarian.  Amenorrhea,  anaemia,  chlorosis, 
the  puerperal  state,  prolonged  lactation,  and  tuberculosis  are 
predisposing  causes.  Ulcer  of  the  stomach  may  result  from  an 
habitual  stooping  position,  as  in  milliners,  seamstresses  and  shoe- 
makers. Burns  of  the  chest  and  abdomen  sometimes  causes 
ulceration  of  the  duodenum  (Bartholow  and  Loomis). 

Symptoms. — It   is    a    chronic    malady   usually.     There    are 
.  three  important  symptoms   of  gastric   ulcer— pain,  indigestion, 


208  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

and  vomiting  (hseniateniesis).  Pain  is  one  of  its  constant  symp- 
toms; at  first  it  is  dnll  and  heavy,  then  it  becomes  burning, 
gnawing,  and  fixed,  boring  through  from  front  to  bach,  and 
occupying  a  space  which  the  finger  may  cover.  It  usually  comes 
on  soon  after  the  ingestion  of  food,  and  lasts  during  the  entire 
period  of  stomach  digestion;  occasionally  it  is  not  present  until 
an  hour  or  so  after  eating.  Very  great  tenderness  is  experienced 
on  pressure  over  the  vertebrae  behind  and  the  seat  of  pain  in 
front.  Attacks  of  gastralgia  occasionally  come  on.  Nausea  and 
vomiting  may  accompany  the  pain;  in  some  instances  there  is 
pyrosis,  or  "water-brash;"  usually  the  vomiting  occurs  when 
the  pain  is  most  severe,  and  temporarily  relieves  the  pain.  The 
matter  vomited  consists,  first  of  the  food  taken  into  the  stomach, 
which  has  a  strong  acid  reaction;  later  it  is  mingled  with  bile. 
Vomiting  of  blood  is  the  most  characteristic  single  symptom,  but 
is  not  pathognomonic.  It  is  absent  in  about  one -third  of  the 
cases,  and  may  occur  only  at  the  monthly  period.  Cachexia  is  a 
late  symptom,  the  appetite  is  rarely  impaired,  sometimes  it  is 
even  increased.  The  face,  when  the  pain  is  intense,  is  "drawn" 
and  haggard,  which  by  some  is  regarded  as  characteristic  of 
ulcer  of  the  stomach.  Obstinate  constipation  is  the  rule  in  ulcer 
of  the  stomach,  but  hemorrhage  may  cause  diarrhoea.  The  blood 
gives  to  the  dejections  a  dark  color,  and  a  tarry  consistence 
(Bartholow  and  Loomis). 

Differential  Diagnosis. — Gastric  ulcer  may  be  mistaken  for 
cancer  of  the  stomach,  hepatic  colic,  cardialgia,  or  gastralgia, 
and  chronic  gastric  catarrh.  In  cancer  there  is  usually  a  history 
of  hereditary  cancer.  Cancer  is  seldom  met  with  in  persons 
under  forty;  while  ulcer  of  the  stomach  occurs  most  in  young 
adults,  and  is  usually  associated  with  anaemia,  chlorosis,  pro- 
longed lactation,  or  compression  of  the  stomach,  as  in  cases  of 
shoemakers  and  sewing- girls.  The  pain  in  cancer  is  continuous, 
and  described  as  lancinating;  while  in  ulcer  the  pain  is  inter- 
mittent, greatly  increased  by  taking  food,  often  referred  to  the 
lower  dorsal  vertebras,  and  described  as.  gnawing  or  burning.  In 
cancer,,  hamiateniesis  has  a  sooty  or  coffee -ground  appearance, 
while  in  ulcer  it  is  a  bright  red  arterial  blood.  Vomiting,  in 
cancer  does  not  relieve  the  pain,  is  not  very  severe,  and  comes  on 


GASTRIC    ULCER.  209 

late;  but  iu  ulcer  it  is  severe,  comes  ou  early,  and  affords  tem- 
porary relief  from  the  pain.  The  cancerous  cachexia  and  de- 
bility are  present  early  and  steadily  progress  in  cancer;  while  in 
ulcer  there  may  be  pallor,  but  no  characteristic  cachexia.  The 
presence  of  an  epigastric  tumor  establishes  the  diagnosis  of 
cancer.  In  hepatic  colic,  the  pain  is  in  the  region  of  the  gall- 
bladder, and  shoots  to  the  right  shoulder  and  back,  comes  on 
suddenly  and  suddenly  ceases. 

In  cardialgia  or  gastralgia,  the  pain  is  not  excited  or  in- 
creased by  the  introduction  of  food  into  the  stomach,  but  often 
comes  on  when  the  stomach  is  empty,  while  in  ulcer  the  pain  is 
associated  with  ingestion  of  food.  In  cardialgia  or  gastralgia, 
pressure  over  the  epigastrium,  and  the  ingestion  of  food,  relieve 
the  pain;  the  reverse  is  the  case  in  ulcer.  Cardialgia  or  gastral- 
gia is  relieved  by  the  constant  current  and  faradization,  which 
increases  the  pain  of  gastric  ulcer.  In  cardialgia  there  will  be 
a  history  of  neuralgia  in  other  parts  of  the  body. 

In  chronic  gastric  catarrh  with  hemorrhage  there  is  the  his- 
tory of  diseases  of  the  liver,  heart,  lungs  or  kidneys;  while  in 
gastric  ulcer  there  is  usually  no  such  history.  The  pain  in  gas- 
tritis is  not  so  intense  as  in  ulcer.  A  coated  tongue,  great  thirstr 
malaise,  and  pyrexia  are  prominent  in  cases  of  chronic  gastritis, 
and  absent  in  ulcer.  The  vomiting  in  chronic  gastritis  conies 
on  in  the  morning,  and  the  matter  vomited  is  stringy  mucus; 
while  in  ulcer  the  attacks  of  vomiting  usually  follow  the 
taking  of  food  (Bartholow  and  Loomis). 

Prognosis. — Must  be  regarded  as  serious  (Bartholow). 

Treatment. — Rest  the  stomach  by  keeping  the  patient  in  bed, 
and  restricting  the  diet  to  peptonized  milk — a  tablespoonful  to  a 
teacupful  may  be  given  every  two  hours  during  the  clay  and 
night.  Digested  beef-juice  may  also  be  given.  All  vegetables, 
tea,  coffee,  starchy  foods  and  fruits  must  be  prohibited.  If  all 
kinds  of  food  are  rejected,  rectal  alimentation  must  be  practiced, 
four  ounces  of  denbrinized  blood  (containing  four  grains  of 
chloral  to  prevent  its  decomposition)  may  be  thrown  into  the 
rectum  every  six  hours  (Loomis).  Bartholow  regards  one  to 
three  drops  of  Fowler's  solution  three  times  daily  the  most  im- 
portant remedial   agent.     He  also  gives  half- grain  doses  three 


210  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

times  a  day  of  nitrate  of*  silver.  Fifteen  grains  three  times  daily 
of  sub-nitrate  of  bismuth  are  effective.  The  flatulence  may  be 
mitigated  by  sulphite  of  soda,  carbolic  acid,  or  the  alkalies. 
The  constipation  may  be  relieved  by  the  saline  mineral  waters, 
or  by  castor- oil  where  the  patient  will  bear  it.  After  some  im- 
provement has  been  made,  rice,  soft-boiled  eggs,  animal  broths, 
.stale  bread  and  cocoa  may  be  allowed. 

PRESCRIPTIONS  FOR  GASTRIC  ULCER. 

R     Creasoti ITIiv. 

Aquae gij. — M. 

.Sig.:     A  tablespoonful  three  or  four  times  daily.         — Niemeyer. 

R     Liquoris  potassii  arsenitis gss. 

Sig.:  One  drop,  repeated  as  required  to  relieve  the  pain  and 
vomiting.  — Bartholow. 

R  Skimmed  milk  two  parts  and  liquor  calcis  one  part,  mixed 
as  a  steady  diet.  — DaCosta. 

R     Bismuthi  subnitratis gij. 

Pulv.  opii , gr.  iij. — M. 

In  pulv.  no.  xii.  div. 
Sig. :     One  powder  thrice  daily,  followed  continuously  by  the  fol- 
lowing: 

R     Argenti  nitratis gr.  v. 

Tincturse  opii 5iss. 

Aqua?  anisi ad §iiss. — M. 

Sig.:     A  teaspoonful  thrice  daily  with  rest  to  the  stomach. 

— W.  H.  Thomson. 

GLANDS,     (Enlarged  Lynrphatic.) 

Chronic  glandular  enlargement  is  a  very  common  affection. 
It  is  found  in  the  strumous  and  feeble  child  as  a  chronic  and 
slightly  painful  enlargement  of  a  gland  or  glands,  more  particu- 
larly those  beneath  the  jaw  and  about  the  neck. 

At  times  these  glands  suppurate  and  leave  ugly  sores. 

Treatment. — For  the  ordinary  or  strumous  enlargement  of 
the  glands  in  children  there  is  no  drug  equal  to  cod-liver  oil,  the 
syrup  of  the  phosphate,  or  of  the  iodide  of  iron,  or  the  tincture 
of  quinine.  Good  food  and  fresh  air  are  also  essential  points  in 
the  treatment  of  these  cases  (Bryant). 


ENLARGED  GLANDS GLEET.  211 

PRESCRIPTIONS  FOR  ENLARGED  GLANDS. 

R     Potassii  iodidi 3J--iv. 

Syrupi  aurantii  cort ,§j. 

Aqua?  cinnamomii ad §iij. — M. 

Sig. :     A  teaspoonful  in  water  three  times  daily.  — Ringer. 

R     Calcii  sulphidi gr.  vj. 

In  pil.  no.  xxiv.  div. 
Sig.:     One  pill  every  four  to  six  hours.  — Ringer. 

R     Syrupi  ferri  iodidi 3j. 

Sig.:     Five  to  forty  minims,  according  to  age,  well  diluted,  after 
meals.  — Bartholow. 

R     Ungt.  plumbi  iodidi ,$j. 

Sig.:     Apply  to  gland.  — Bartholow. 

R     Ungt.  iodi  comp 5j. 

Sig.:     Apply  to  gland.  — H.  B.  Sands. 

GLEET. 

Is  a  mueo-purulent  discharge  from  the  urethra,,  the  chronic 
stage  of  gonorrhoea.  In  gleet,  a  certain  amount  of  sticky  bluish 
fluid,  often  only  a  drop  at  the  meatus  in  the  morning — continues 
to  be  secreted  after  gonorrhoea,  from  altered  patches  of  the 
urethra,  or  coming  from  the  congested  membrane  behind  a 
stricture.  Gleet,  then,  is  a  symptom  of  two  structural  lesions, 
and  signifies  that  there  are  patches  of  congestion  in  the  canal, 
covered  or  not  by  granulations,  or  that  stricture  exists,  and  that 
the  discharge  comes  from  behind  it.  Prostatic  congestion  and 
enlargement  are  also  liable  to  be  attended  by  a  slight  gleet. 

Gleet  tends  to  last  indefinitely,  and  an  individual  so  affected 
is  a  ripe  subject  for  bastard  gonorrhoea.  The  simple  congested 
patches  which  furnish  the  gleety  discharge,  are  kept  from  getting 
well  by  alcohol,  malt  liquors,  sexual  excesses,  fatigue,  violent 
exercise,  anaemia,  gouty  or  strumous  habit.  Gleet  is  contagious 
when  purulent,  but  only  if  it  contains  gonococci.  All  urethral 
discharges  become  gleety  before  they  cease  (Keyes). 

Treatment. — Eyerything  earthly  has  an  end,  even  a  gleet,  as 
Thiry  has  sagely  remarked,  and  no  treatment  will  succeed  where 
over-treatment  has  only  served  to  keep  up  the  evil.    As  stricture 


212  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

already  present  or  forming  is  the  most  common  of  all  causes  for 
continued  gleet,  it  should  be  sought  for  and  treated.  Where  no 
lesion  is  discovered,  the  urine  must  be  kept  mildly  alkaline, 
sexual  intercourse  avoided,  and  copabia  or  oil  of  sandal-wood  or 
cubebs  may  be  given.  Stimulating  or  astringent  injections 
should  be  employed,  such  as  follows : 

R     Zinci  chlpridi gr.  j. 

Aquae oj- — M. 

Or, 

R     Cupri  sulphatis gr.  j. 

Aqua;  5J- — M. 

Or, 

R     Ferri  persulphatis 3ss. 

Aquas  o  vj — M. 

Or, 

R     Zinci   sulphatis gr.  l-ii]. 

Liquoris  plumbi  subacetatis..dil...Sj- — M. 
Or, 

R     Aluminis  exust gr.  x. 

Aquas  5j- — M. 

Or, 

R      Acidi  tannici gr.  v-x. 

Aqua;  oj- — M. 

Or, 

R     Zinci  permanganatis gr.  ss-ij. 

Aqua?    oj- — M. 

0r' 

R     Hydrargyri  chloridi  corrosi gr.  ss. 

Aqua; oxij . — M. 

Alcohol  is  often  efficient,  and  may  be  used  as  follows  :  To 
commence  with  two  parts  of  rose  water  to  one  of  red  wine,  and 
continue  increasing  the  latter  until  pure  wine  can  be  used. 
Glycerine  may  be  combined  with  any  of  the  above  formulas. 

Three  points  must  be  remembered  in  regard  to  injections  : 
1.  They  must  not  be  too  strong.  2.  They  must  be  continued  for 
at  least  ten  days  after  the  discharge  ceases.  3.  They  may 
produce  a  hypersecretion  of  the  urethral  mucus,  and  thus  keep 
up  the  discharge.  Any  injection,  thrown  too  deeply  into  the 
canal,  may  light  up  epididymitis,  or  cystitis. 

Deep  urethral  injections  may  be  used,  if  the  discharge 
comes  from  the  membranous  urethra.  Locate  the  granulating 
area  with  a  bulb,  and  there  deposit  three  minims  of  a  solution 


GLEET.  218 

of  nitrate  of  silver  of  a  strength,  of  gr.  i.  to  grs.  xx.  to  the  ounce 
of  water.     Repeat  the  application  three  times  a  week. 

Occasionally  a  fifty  per  cent  solution  in  water  of  the  gly- 
cerole  of  tannin  will  arrest  a  deep  urethral  discharge  after  the 
nitrate  of  silver  fails.  Sometimes  the  passage  of  a  well-oiled 
smoothly-polished  sound  as  large  as  the  meatus  will  admit,  re- 
23eated  every  third  day  will  cure  the  discharge  (Keyes). 

PRESCRIPTIONS  FOR  GLEET. 

R     Potassii  permanganatis    gr.  i  iij. 

Aquae  destillatre 3j . — M. 

Sig. :     Use  as  injection.  — Keyes. 

R     Zinci  sulphatis gr.  vj. 

Tinct.  opii 3j. 

Tinct.  catechu 31J . 

Aqua?  rosre ad §ij . — M. 

Sig.:     Use  as  an  injection  three  times  a  day.  — Witherstine. 

GOITRE.     (Simple  and  Exophthalmic). 

Simple  goitre,  or  Derbyshire  neck,  as  it  is  generally  known 
in  England,  is  very  common.  In  its  most  usual  form  it  appears 
as  a  simple  bronchocele,  or  hypertrophy  of  the  thyroid  gland. 
They  may  press  upon  surrounding  parts  and  cause  dyspnoea, 
cough,  and  difficult  deglutition.  All  these  tumors  rise  and  fall 
with  the  larynx  in  deglutition  (Bryant). 

Cause. — In  the  Derbyshire  district  it  is  generally  believed 
that  it  is  from  the  water  impregnated  with  chalk,  lime,  and  mag- 
nesia, that  the  disease  is  produced  (Bryant). 

Treatment. — Simple  goitres  are  to  be  treated  on  ordinary 
principles  by  tonics,  fresh  air,  etc.  The  air  of  the  room  should 
be  kept  iodized  by  means  of  solid  iodine  put  into  a  box  with  a 
jjerforated  lid.  Bryant  has  seen  goitres  rapidly  disappear  under 
this  treatment.  "With  the  above  treatment  he,  at  times,  rubs  in 
an  ointment  of  the  iodide  of  ammonium,  a  drachm  to  an  ounce. 
To  paint  a  goitre  with  the  tincture  of  iodine  is  useless.  Dr. 
Mouat  of  Bengal,  spoke  very  highly  of  an  ointment  of  the  binio- 
dide  of  mercury  (three  drachms  to  a  pound  of  lard)rubbedin  for 


214  A    COMPENDIUM    OF    PRACTICAL     MEDICTJSTE. 

ten  minutes  in  the  sunshine.  He  gives  his  cases  of  recovery  by 
the  thousands.  Of  late  years,  Bryant  injects  20  or  30  drops  of  a 
mixture  of  equal  parts  of  tincture  of  iodine  and  alcohol,  with 
success.     In  some  cases,  he  reports  a  cure  with  one  injection. 

Exophthalmic  Goitre  is  a  disease  characterized  by  exophthal- 
mus  (protrusion  of  the  eyeballs),  enlarged  thyroid,  dilatation  of 
the  arteries,  palpitation  of  the  heart,  and  anaemia.  In  Germany 
it  is  known  as  Basedow's  disease;  in  England  as  Graves'  disease. 

Causes. — Bartholow  gives  moral  emotions,  fright,  chagrin, 
reverses  of  fortune  and  a  peculiar  condition  of  the  nervous  sys- 
tem as  causes.  DaCosta  says,  "This  disease  is  most  commonly 
observed  in  females,  and  connected  with  hysteria,  neuralgia,  and 
uterine  disturbance,  and  is  considered  to  be  due  to  an  affection 
of  the  cervical  sympathetic  nerve."  According  to  Loomis  the 
enlargement  of  the  thyroid  body  is  due  to  dilatation  of  its  vessels 
and  protrusion  of  the  eyeball  to  a  dilatation  of  the  vessels  behind 
the  globe. 

Symptoms. — This  disease  may  come  on  suddenly  or  slowly. 
Palpitation  is  most  often  the  first  symptom.  The  heart  beat  is 
always  above  normal  and  may  reach  200  per  minute.  A  soft 
blowing,  murmur  is  heard  at  the  base  and  over  the  carotids. 
Sometimes  the  goitre  is  the  first  symptom  observed.  The  thyroid 
gland  occasionally  enlarges  in  pregnancy,  but  this  is  accidental. 
Exophthalmus  may  be  the  first  symptom.  There  is  a  staring  ex- 
pression. There  is  more  or  less  fever  followed  by  sweat.  The 
patient  is  nervous,  apprehensive,  irritable  and  lachrymose.  The 
patient  is  pale,  anaemic,  and  amenorrhcea  is  present  in  most  cases 
(Bartholow  and  Loomis). 

Prognosis. — Must  always  be  guarded  (Loomis). 

Treatment. — Traube  achieved  great  success  with  five  grains 
of  quinine  one  da}r,  and  ten  grains  of  iron,  in  the  form  of  Val- 
let's  mass,  the  following  day.  Good  results  have  been  obtained 
from  belladonna  and  ergot.  Bartholow  has  found  galvanization 
of  the  cervical -sympathetic  and  the  pneumogastric,  by  placing 
the  of  anode  under  the  ear,  and  the  cathode  at  the  epigastrium 
to  be  of  the  highest  efficiency. 


GOITRE GONORRHOEA.  215 

PRESCRIPTIONS  FOR  GOITRE. 

R     Tincture  iodinii  corap 5J. 

Sig. :     Apply  locally  with  a  brush.     Also  five  to  fifteen  minims 
in  water  three  times  daily  internally.     (In  simple  goitre). 

— Bartholow. 

R     Ungt.  hydrarg.  iodidi  rubri Bj. 

Sig.:     Rub  in  a  piece  the  size  of  a  pea  and  expose  to  the  sun. 
(In  simple  goitre).  — Ringer. 

R     Potassii  bromidi §ss. 

In  pulv.  no.  xii.  div. 
Sig.:     A  powder  in  half  a  tumblerful  of  water  three  times  daily. 
(In  exophthalmic  goitre).  — Hutchinson. 

GONORRHEA, 

Is  a  urethral  inflammation,  a  strictly  local  affection,  exerting 
no  poisonous  action  upon  the  blood,  and  is  the  most  venereal  of  all 
the  venereal  diseases.  Urethritis  signifies  simply  inflammation 
of  the  urethra,  consequently  gonorrhoea  is  urethritis,  but  ureth- 
ritis may  not  be  gonorrhoea.  Gonorrhoea  alone  produces 
gonorrhoea.  The  term  urethritis  shoulol  be  reserved  for  all 
inflammatory  urethral  olischarges  having  another  origin,  and  for 
all  cases  of  doubt.  "It  is  better  that  a  hundred  of  the  guilty 
should  escape  than  that  one  innocent  person  should  be  accused.11 
Experience  proves  beyonol  a  doubt  that  urethral  inflammation 
attended  by  an  abundant  discharge  may  be  acquired  by  a  healthy 
young  lover  from  his  equally  healthy  young  mistress,  by  a  young 
husband  from  his  wife,  and  presenting  nothing  to  differentiate  it 
from  gonorrhoea  (Keyes). 

Causes. — Gonorrhoea  is  a  notoriously  contagious  disease,  and 
it  may  be  acquired  from  any  person  having  it,  by  the  mere  con- 
tact of  the  discharge  with  the  mucous  membrane  of  the  urethra. 
The  only  mucous  membranes  of  the  body  capable  of  taking  on 
inflammation  from  the  contact  of  gonorrhoeal  pus  are,  the  ureth- 
ral, vesical,  vaginal,  uterine,  tubal,  conjunctival  and  rectal.  A 
peculiai  vegetable  parasite,  called  the  gonococcus,  is  the  real 
cause  of  gonorrhoea.  The  three  most  common  forms  of  urethral 
flow  are  urethritis,  bastard  gonorrhoea,  and  gonorrhoea.  Mechan- 
ical violence,  such  as  the  rough  use  of  instruments  in  the  urethra, 


216  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

chemical  violence,  such  as  acid  urine,  cantharides,  strongly  acid 
or  alkaline  injections,  leucorrhceal  discharges,  lochial  and  the 
menstrual  flow  may  be  sufficient  to  cause  urethritis  in  a  perfectly 
healthy  subject.  In  these  cases  the  patient  has  a  slight  uneasy 
sensation  at  the  meatus,  a  little  smarting,  and  a  pearly  drop  in 
the  morning  (Keyes). 

BASTARD  GONORRHEA. 

A  patient  who  has  previously  had  gonorrhoea,  comes  with  a 
little  oozing  from  the  meatus,  perhaps  with  no  itching  sensation, 
nor  any  smarting  on  urination,  and  states  that  (perhaps  after 
copious,  libations  of  ale,  beer,  or  champagne)  he  sinned  with  a 
suspicious  party,  and  that  while  examining  himself  on  the  fol- 
lowing morning,  found  the  little  opaline  drop.  Such  a  person 
has  a  damaged  urethra,  a  patch  of  chronic  congestion,  or  a  stric- 
ture, and  he  has  irritated  this  surface  and  given  himself  a  dis- 
charge.    This  is  not  true  gonorrhoea;  it  is  bastard  (Keyes). 

Symptoms. — The  period  of  incubation  varies  from  a  few 
hours  to  fourteen  days.  The  first  symptom  in  true  gonorrhoea  is 
usually  noticed  on  the  fifth  to  seventh  day.  A  tickling,  teasing, 
itchy  irritation  is  first  felt  at  the  orifice  of  the  urethra.  A  slight, 
bluish  discharge  is  seen  between  the  lips  of  the  meatus,  which 
swell  a  little  and  become  reddened.  A  slight  stinging  is  felt  on 
urination.  The  quantity  of  the  discharge  increases,  and  it 
becomes  opaline.  Greater  pain  is  felt  in  passing  water.  The 
meatus  feels  hot  and  sore.  After  the  fifth  day  from  its  appear- 
ance the  discharge  becomes  much  more  copious.  It  gets  thick 
and  purulent,  and  soon  acquires  a  greenish  color.  Pain  is  now 
felt  all  along  the  pendulous  portion  of  the  urethra,  and  the  canal 
is  very  sensitive  to  pressure.  Pain  may  be  complained  of  in  the 
groin,  testicle,  perineum,  cord  and  back.  The  stream  of  urine  is 
small,  forked,  and  dribbling  on  account  of  the  inflammation  of 
the  urethra,  and  retention  may  come  on  if  the  patient  has  pre- 
viously had  a  stricture.  The  prepuce  may  become  cedematous, 
occasioning  phimosis  or  paraphimosis.  Erections,  also,  at  this 
time  become  painful,  threatening  chordee.  Chordee  is  most  fre- 
quent during  the  night  and  toward  morning.     After  the  disease 


BASTARD    GONORRHOEA.  217 

has  continued  at  its  height  for  from  one  to  three  weeks,  the  pain 
on  urination  ceases,  and  the  discharge  becomes  more  watery,  and 
finally  diminishes  to  a  drop  in  the  morning. 

The  Duration  of  Gorlorrhwa  is  Variable. — A  well-managed 
case  lasts  from  three  to  six  weeks  as  a  rule;  but  the  discharge 
may  continue  for  months  and  even  years.  A  first  gonorrhoea  is 
the  most  severe,  but  is  the  most  certain  to  get  perfectly  well.  ■  If 
the  disease  does  not  get  well,  it  passes  into  the  gleety  stage 
(Keyes). 

Complications. — Balanitis,  phimosis,  chordee,  possible  reten- 
tion, haemorrhage,  epididymitis,  orchitis,  gonorrhoeal  cystitis, 
gonorrhoeal  rheumatism,  gonorrhoeal  ophthalmia  and  gonorrhoeal 
conjunctivitis  are  the  most  important  (Keyes). 

Treatment. — There  are  two  methods  of  treatment,  the  abor- 
tive and  the  rational. 

The  Abortive  Treatment. — Consists  in  hot  irrigation  to  soothe 
the  membrane  and  wash  out  the  poison,  and  in  the  use  of  anti- 
septic, or  antiparasitic  drugs  to  destroy  the  gonococcus.  Nitrate 
of  silver  and  chloride  of  zinc  do  more  harm  than  good.  The 
present  favorites  are  prolonged  irrigation  and  varying  strengths 
of  the  bichloride  of  mercury.  If  the  abortive  treatment  is  to  be 
tried,  it  should  be  used  within  the  first  twenty-four  hours  of  the 
commencement  of  an  attack.  The  method  by  anterior  irrigation 
is  simply  to  put  a  quart  of  tepid  or  hot  water,  at  a  strength  of 
half  a  grain  of  bichloride  of  mercury  in  twenty-two  ounces 
(about  1  in  20,000),  into  a  fountain  syringe,  and  press  the  blunt 
glass  nozzle  into  the  urethra,  so  that  the  water  shall  trickle  out 
slowly  alongside  of  the  glass  nozzle.  Instead  of  the  fountain 
syringe  a  little  red  soft  rubber  irrigator,  called  the  universal  in- 
jector, may  be  used.  This  irrigation  is  repeated  three  times  a 
day. 

The  Rational  Method. — Consists  first  in  observing  the  hy- 
giene of  gonorrhoea,  which  is  as  follows:  Absolute  continence 
until  at  least  ten  days  after  the  entire  cessation  of  the  discharge, 
and  avoidance  of  anything  liable  to  induce  sexual  excitement. 
No  alcoholic  stimulants  of  any  sort,  and,  above  all,  no  malt 
liquor  should  be  drunk  during  the  treatment. 


218  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Increasing  Stage. — If  the  case  is  seen  early  enough,  mild 
bichloride  irrigation  may  be  tried.  The  bicarbonate  of  soda,  or 
better  still,  the  citrate  of  potash  may  be  given  in  doses  of  gr. 
x-xx.  during  the  second  hour  after  each  meal  throughout  the 
entire  treatment,  to  keep  the  urine  alkaline.  Occasionally  twenty 
grain  doses  of  the  bromide  of  potassium  will  moderate  the  ardor 
urinse  better  than  the  citrate. 

The  following  is  a  good  combination: 

R     Potassa?  citratis 5ii--vj. 

Bals.  copabia? 3iii--yj. 

Extracti  hyocyami  fluidi 5ss.-ij. 

Syrupi  acacia? §iss. 

Aqua?  mentha?  piperita? q.  s....oiij- — M. 

Sig. :     Shake.     Teaspoonful  in  water. 

Another  aid  to  easy  micturition  is  Milton's  plan  of  immers- 
ing the  penis  in  hot  water  before  and  during  the  act.  A  suspen- 
sory bandage  should  be  worn.  When  injections  are  used  in  the 
increasing  stage,  they  should  be  very  mild  ones,  as  follows: 

R     Liq.  plumbi  subacetatis  dil §j. 

Morphia  acetatis gr.  j . — M. 

Or, 

R     Zinci  sulphocarbolat gr.  i-ij. 

Aqua? §j- — M. 

Or, 

R     Zinci  sulphatis gr.  i-iij. 

Aqua? 5j  • — M. 

(In  less  acute  fom  s).     Or, 

R     Zinci  sulphatis gr.  i.-iij. 

Liq.  plumbi  subacetatis  dil Sj- — M. 

Or, 

R     Aluminis  exust gr.  x. 

Aqua? 5j. — M. 

Or,  if  more  astringency  is  required, 

R     Acidi  tannici gr.  v.-x. 

Aqua? 3J- — M. 

A  suitable  injection  may  be  used  two  or  three  times  a  day. 

Stationary  Stage. — This  stage  lasts  from  one  to  three  weeks 
with  very  little  change.  The  treatment  of  the  first  stage,  with- 
out any  injections,  must  be  kept  up.  Prolonged  and  frequent 
warm  baths  are  beneficial  in  this  stage.  The  most  difficult  part 
of  the  treatment  of  this  stage  is  to  soothe  the  painful  erections 


GONOEKHCEA.  219 

and  keep  off  chordee.  The  best  course  is  for  the  patient  to  keep 
his  urine  dilute  and  alkaline,  and  to  immerse  the  penis  for  a  long 
time  in  very  hot  water  before  retiring.  He  should  sleep,  lightly 
covered,  on  his  side,  on  a  hard  bed,  after  a  small  evening 
meal.  Bromide  of  potassium,  in  doses  of  from  thirty  to  sixty 
grains  at  night  in  water,  repeated  once,  if  necessary,  will  control 
chordee  in  some  cases.  When  a  patient  wakes  with  chordee,  the 
penis  should  be  plunged  into  the  coldest  water  which  is  at  hand, 
or  laid  along  a  piece  of  iron  which  has  been  exposed  to  the  cold. 
He  must  not  "  break  the  chordee." 

Decreasing  Stage. — Injections  are  of  great  service  in  the 
stage  of  decline.  Any  of  those  already  given  may  be  used.  If 
copaiba  is  well  borne  and  properly  administered,  it  is  the  most 
efficient  of  the  anti-gonorrhceal  internal  remedies.  Pills  or  tablets 
containing  copaiba,  sandal -wood  oil,  cubebs  and  oil  of  turpen- 
tine sometimes  act  better  than  any  one  alone.  They  may  cause 
an  eruption  to  appear  (Keyes).  The  treatment  of  the  compli- 
cations of  gonorrhoea  will  be  found  in  the  proper  order. 

PRESCRIPTIONS  FOR  GONORR(EHA. 

R     Balsami  copaiba?. 

Spiritus  retheris  nitrosi. 

Spiritus  lavandulae  comp,  aa 3ss. 

Liquoris    potassas 3j. 

Mucil.  acacias,  q.  s.,  ad §iv. — M. 

Sig.:     Shake,  and  take  one  teaspoonful.     ("Lafa}^ette  Mixture.") 

— Charity  Hospital. 

R     Balsami  copaiba? ^ss. 

Tinct.  ferri  muriatis. 

Tinct.   cantharidis aa 5 ij • 

Glycerinae £ss. 

Syrupi q.  s.,  ad $iv. — M. 

Sig.:     A  teaspoonful  after  meals.  — Burnstead. 

R     Potassii  citratis o^s-j. 

Sp iritus  limonis 5ss. 

Syrupi  simplicis  §ij. 

Aquas 5j. — M. 

Sig.:     A  dessertspoonful  well   diluted  three  or  four  times  daily, 
fasting.     (In  the  first  stage).  — Keyes. 


220  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

R     Liq.  hydrarg.  chlor.  corros..(T¥Vo)  Qj- 
Sig. :     Distend   the  vagina  with   a   speculum   and   cleanse  thor- 
oughly with  the  above  solution.     Then   dust  over  and  rub  in  iodo- 
form,   and  tampon     the     vagina    with    iodoform    gauze.     Repeat  in 
three  or  four  days.     (In  female.)  — Schwartz. 

GOUT. 

In  a  constitutional  malady,  inherited  and  characterized  by 
paroxysms  of  severe  pain  in  small  joint — the  great  toe  usually — - 
due  to  the  presence  of  uric  acid  in  the  blood,  and  the  deposit  of 
the  urates  in  the  structure  of  the  joints  and  throughout  the 
body.  Gout  in  the  foot  is  called  podagra;  in  the  hand  chiragra; 
in  the  knee  gonagra.     (Bartholow.) 

Causes. — The  gouty  diathesis  may  be  inherited  or  acquired. 
Gout  is  a  disease  of  middle  life.  The  direct  exciting  cause  is 
over- eating  and  the  use  of  alcohol.  Of  the  alcoholic  beverages, 
the  sweet  wines  and  malt  liquors  are  considered  more  gouty  than 
spirits.  Lack  of  exercise,  and  failure  of  the  excretive  power  of 
the  kidney  and  lead -poisoning  are  influential  factors.  Men  suf- 
fer from  attacks  of  gout  much  more  frequently  than  women.  As 
a  disorder  of  the  upper  classes,  gout  has  had  a  position  of  dis- 
tinction, and  S}Tlenham  consoled  himself  for  his  sufferings  from 
gout  by  the  reflection  that  it  is  an  eminently  respectable  dis- 
ease, by  which  more  rich  men  than  paupers,  more  wise  men  than 
fools  are  afflicted.  It  is  the  large  consumption  of  beer  which  de- 
velojDS  gout  in  the  laboring  classes.  Attacks  are  sometimes  at- 
tributed to  prolonged  intellectual  exertion,  anxiety  of  mind, 
bodily  fatigue,  and  exposure  to  cold,  and  are  more  likely  to  oc- 
cur in  the  spring  and  autumn  than  at  other  seasons  of  the  year. 
(Bartholow,  Flint  and  Loomis.) 

Symptoms. — Acute  Gout. — Usually  between  midnight  and 
four  or  five  in  the  morning  the  patient  wakes  with  a  burning, 
throbbing  pain  in  the  ball  of  the  great  toe,  which  the  slightest 
j)ressure  greatly  intensifies.  The  affected  joint  becomes  red, 
swollen,  hot  and  shining;  the  veins  are  distended,  and  it  resem- 
bles a  joint  about  to  supi3urate.  The  temperature  may  in  a 
severe  attack  reach  105°  F.  The  pulse  is  full  and  bounding,  but 
compressible.     The  pain  in  the  affected  joint  is  so  great  that  the 


GOUT.  221 

patient  cannot  move  it.  He  tosses  about  for  hours,  until  finally, 
in  a  profuse  perspiration,  falls  asleep.  In  a  few  hours  he 
awakes  almost  free  from  pain,  and  remains  so  during  the  day; 
but  about  the  same  hour  the  next  night  there  is  a  recurrence  of 
the  local  pain  and  the  fever.  These  nocturnal  attacks  continue 
for  two  or  three  days,  then  the  maximum  of  pain  is  reached.  At 
the  end  of  a  week,  they  have  gradually  subsided.  Following 
the  attack,  there  is  a  feeling  of  well-being.  During  an  attack, 
there  are  anorexia,  coated  tongue  and  constipation.  The  urine 
is  scanty  and  high-colored.  The  bladder  is  irritable,  and  there 
is  a  scalding  sensation  on  urination.  An  individual  may  have 
only  a  single  attack,  but  usually  a  second  supervenes  within  a 
year. 

Chronic  Gout. — When  tophi  (deposits  of  urate  of  sodium) 
form  around  the  joints,  and  they  become  distorted  or  crippled  so 
that  walking  becomes  difficult,  it  is  called  chronic  gout.  Nodules 
of  the  deposit  are  frequently  seen  on  the  helix  of  the  ear,  some- 
times on  the  eyelids  and  occasionally  on  the  face.  When  the 
stomach,  intestine,  lungs,  heart,  liver,  kidneys  and  brain  are 
gouty,  it  is  called  irregular  and  misplaced  gout.  Gout  is  a  very 
chronic  disease.  It  sometimes  produces  subluxation  of  the 
joints,  and  this  combined  with  the  tophaceous  nodules  give  rise 
to  striking  deformities  (Flint  and  Loomis). 

Differential  Diagnosis. — Gout  may  be  mistaken  for  rheuma- 
tism. Gout  attacks  the  small  and  rheumatism  the  large  joints. 
A  rheumatic  attack  is  of  longer  duration  than  a  gouty  paroxysm. 
In  gout  the  fever  is  slight,  in  rheumatism  it  is  high.  In  acute 
rheumatism,  the  heart  is  frequently  involved,  in  gout  rarely. 
The  gouty  attack  coming  on  at  night  in  the  great  toe  joint  is  in 
marked  contrast  to  the  onset  of  rheumatic  fever.  Acute  articu- 
lar rheumatism  is  a  disease  of  early  adult  life,  while  gout  is  rare 
before  thirty-five.  In  gout  there  is  a  history  of  high  living,  in 
rheumatism  there  will  be  a  history  of  exposure  or  exhaustion. 
In  gout  there  is  an  excess  of  uric  acid  in  the  blood  (uricsemia  ), 
this  is  never  the  case  in  rheumatism,  but  is  pathogmonic  of  gout. 
Tophaceous  masses  occurring  in  the  external  ear,  varying  in  size 
from  that  of  a  pin's  head  to  that  of  a  split  pea,  are  often  of  great 
assistance  in  the  diagnosis  (Loomis). 


222  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — 1.  General  Hygiene. — Gouty  subjects  should 
take  systematic  exercise  in  the  open  air,  especially  horse-back 
riding,  walking,  rowing,  etc.  A  country  residence,  a  warm,  dry 
climate,  are  preferable.  The  patient  should  be  warmly  clad  in 
flannel,  retire  and  rise  early,  and  avoid  severe  physical  and  mental 
strain. 

2.  Dietetics. — Starving  will  not  cure  gout.  The  principal 
articles  of  diet  should  be  beef,  mutton,  chicken,  bread,  milk  and 
fruits.  All  pastry,  eggs,  tea,  coffee,  alcohol,  cheese,  dried  meats, 
tomatoes  and  strawberries  should  be  avoided.  Alkaline  mineral 
waters,  seltzers,  vichy  and  lithia  may  be  taken  with  and  after 
meals. 

3.  External  Treatment. — The  affected  part  should  be 
raised  above  the  body  and  wrapped  in  flannel.  When  the  pain 
is  intense  opium  may  be  applied  to  the  joint.  Vapor  and  Turk- 
ish baths  should  be  taken  weekly. 

4.  Internal  Treatment. — Colchicum  and  the  alkalies  are 
our  chief  remedies  during  the  paroxysm.  For  thirteen  centuries 
colchicum  has  been  used  in  this  disease.  Loomis  gives  one  of 
the  following  pills  every  three  hours  until  the  specific  purgative 
action  of  the  colchicum  is  obtained: 

R     Pulv.  ipecac 

Extracti  colchi  acet 

Hydrarg.  protochlor  (calomel)  ... 

Ext.  aloes  fld aa  gr.  j. 

Ext.  nucis  vomicae gr.  \. — M. 

Carbonate  of  potash,  Rochelle  salts  and  citrate  of  lithia  are 
important  adjuvants  to  the  colchicum  treatment.  In  chronic 
gout  tonics,  as  iron,  arsenic,  etc.,  are  usually  demanded  (Loomis). 

PRESCRIPTIONS  FOR  GOUT. 

R     Magnesii  sulphatis §j. 

Magnesias  optima?  oij- 

Vini  colchici  rad §j. 

Aquas  menthse  pip §x. — M. 

Sig. :     A  tablespoonful  every  hour  until  it  operates.  — Scudmore. 

R     Tinct.  iodini 3ijss. 

Gly  cerinee §ij . — M. 

Sig.:     A  tablespoonful  thrice  daily.  — Granville. 


GUMS GASTRITIS.  223 

R     Paraldehyde 5ss. 

Syrupi  simplicis  Siss. — M. 

Sig. :     A  teaspoonful  to  a  tablespoon ful,  well  diluted  when  re- 
quired (for  gouty  insomnia).  — Hodgson. 

R     Granulated  efferv.  lithii  citrat  §iv. 

Sig.:     One  or  two  teaspoonfuls  in  water  three  times  daily. 

— Mattison. 

GUMS.     (Affections  of). 

When  the  gums  are  spongy  and  ill-conditioned,  and  mani- 
fest a  tendency  to  recede  from  the  teeth,  the  following  local 
application  is  very  serviceable: 

R     Aluminis 5j. 

Vini O.j. 

Tinct.  cinchona? '. ....§ss. 

Tinct.  myrrhse 5ij- 

Mel.  rosse Sij. — M. 

Sig.:     As  a  mouth  wash.  — Bartholow. 

The  glycerite  of  tannin  is  a  useful  application  for  spongy 
and  bleeding  gums.  When  fetor  is  present,  carbolic  acid  and 
iodoform  are  most  serviceable.  The  tincture  of  benzoin,  with 
or  without  glycerine,  is  very  effective. 

PRESCRIPTIONS  FOR  SPONGY  OR  BLEEDING  GUMS. 

R     Chloral  hydratis 

Tinct.  cochlearise aa 5 iss. — M. 

Sig.:     Apply  to  gums,  by  means  of  a  pleget  of  cotton  every  day 
or  two.     (For  gingivitis  of  pregnancy).  — Pinard. 

R     Tinct.  myrrhse oih-iv. 

Aquse  vel.  infusi  cinchonas siv. — M. 

Sig.:     Use  as  a  gargle.    (For  spongy  or  ulcerated  gums). 

—Phillips. 

R     Glycerite  acidi  tannici 3j. 

Sig. :     Apply  with  camel's  hair  brush.  — Bartholow. 

GASTRITIS.     (Toxic.) 

Is  an  acute  inflammation  of  the  stomach,  caused  by  the  in- 
gestion of  irritant  and  corrosive  poisons. 


224  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — Besides  the  vomiting  which  occurs  immediately 
or  very  soon  after  swallowing  the  irritant,  corrosive  or  toxic  sub- 
stance, purging  sets  in  and  the  same  sloughs  of  the  tissues  dis- 
charged by  vomiting  pass  also  by  stool.  In  the  case  of  corrosive 
sublimate  and  the  metallic  salts  generally  there  occur  intense 
colic  and  tenesmus,  and  the  discharges  consist  of  mucus  and 
blood  and  strongly  simulate  dysentery.  Arsenic,  the  salts  of 
mercury,  copper,  zinc  and  nitrate  of  potash,  produce  an  intense 
inflammation.  Sausages,  hams,  cheese,  fish,  etc.,  that  have  under- 
gone decomposition  produce,  in  a  few  minutes  or  hours  after 
swallowing  them  a  violent  gastritis.  There  is  great  anxiety  and 
depression,  a  weak,  rapid  pulse,  cold  skin,  covered  with  cold 
sweat,  intense  internal  heat  and  thirst  and  burning  in  the  gullet 
and  fauces  (Bartholow). 

Prognosis. — Death  may  occur  from  the  immediate  effects  of 
the  poison.  Recovery  may  ensue  if  the  injury  done  is  not  too 
great  for  repairs. 

Treatment. — Vomiting  is  to  be  encouraged  by  the  free  use  of 
demulcent  drinks.  If  the  toxic  agent  consists  of  an  acid,  as 
speedily  as  possible,  weak  alkalies,  lime  water,  soda,  common 
soap,  etc.,  should  be  given.  The  other  poisons  require  their 
proper  antidotes.  The  stomach  pump  should  be  used  not  only  to 
remove  the  poison  remaining,  but  to  thoroughly  wash  out  the 
stomach.  To  allay  the  pain,  give  a  hypodermic  injection  of 
morphine.  Ice  should  be  given  freely  and  an  ice-bag  applied  to 
the  epigastrium.  No  food  should  be  given,  but  a  little  cold  milk 
at  short  intervals  (Bartholow  ). 

GINGIVITIS.     (See  Gums,  Affections  of.) 

GLAUCOMA. 

This  term  is  used  to  express  a  morbid  condition  character- 
ized by  an  increase  in  the  hardness  of  the  eye-ball.  The  word 
glaucoma,  literally  signifies  green,  and  was  employed  because  in 
certain  advanced  cases  the  pupil  acquires  a  greenish  hue.  The 
standard  of  ocular  tension  varies  in  its  physiological  limits. 
In  women  it  is  normally  less  than  in  men,  in  children  than  in  ad- 
ults. An  average  of  twelve  inches  of  water  is  normal.    The  sense 


GLAUCOMA.  225 

of  touch  must  be  relied  upon  for  the  tension,  and  one  finger  of  each 
hand  is  to  be  lightly  pressed  upon  the  e}^e  as  when  feeling  for 
fluctuation  in  an  abscess.  When  the  tension  is  increased  it  is 
called  plus,  when  diminished  minus  tension  (Noyes). 

Varieties. — 1.  Glaucoma  simplex.  2.  Glaucoma  with  inflam- 
mation. 3.  Glaucoma  hemorrhagicum.  4.  Secondary  glaucoma 
(Noyes). 

Symptoms. — The  simple  is  the  most  frequent  variety,  is  in- 
sidious and  very  slowly  progressive,  occurs  most  often  after  mid- 
dle age  and  in  hypermetropic  eyes.  The  external  appearance  of 
the  eye  may  be  normal  except  a  notable  whiteness  of  the  sclera. 
The  field  of  vision  will  be  restricted  on  the  nasal  side  to  a  greater 
or  less  degree.  The  tension  of  the  eye  will  be  increased.:.  Un- 
commonly strong  glasses  for  reading  will  be  needed.  Attacks  of 
sudden  obscurity  of  sight  for  some  minutes  have  taken  place.  At 
times  colored  rings  will  be  observed  around  a  lamp  or  gas  flame. 
It  is  usual  for  one  eye  to  be  affected  sometime  before  the  other. 
It  may  occupy  five  to  fifteen  years  for  its  development,  and  in 
old  persons  be  mistaken  for  senile  cataract.  When  the  glaucoma 
becomes  chronic  there  will  be  greatly  increased  hardness  with  the 
pupil  widely  and  unequally  dilated  and  fixed,  the  cornea  more 
or  less  anaesthetic,  the  pupil  will  have  a  dusky  or  even  greenish 
hue,  and  the  globe  enlarged  tortuous  arteries. 

In  the  inflammatory  variety,  the  person  is  apt  to  be  taken 
during  the  night  with  severe  pain  in  the  eye  and  forehead. 
There  may  be  rise  of  temperature-,  rapid  pulse  and  vomiting. 
On  inspection  of  the  eye,  the  cornea  may  be  hazy,  the  aqueous 
will  be  turbid,  the  iris  and  lens  pressed  toward  the  cornea,  the 
pupil  will  be  obscured  and  dilated,  and  the  iris  discolored,  and 
diminished  to  a  narrow  ring.  It  is  not  easy  to  feel  the  tension 
through  the  swollen  lids,  and  the  pressure  will  be  painful.  Vis- 
ion is  impaired  or  wholly  lost  in  a  few  hours. 

In  the  hemorrhagic  variety,  there  is  effusion  of  blood  in 
the  retina,  or  optic  nerve,  and  sometimes  in  the  vitreous.  There 
is  a  sudden  loss  of  sight,  followed  by  j)ain  and  inflammation. 

In  the  secondary  variety,  there  is  increased  ocular  tension, 
due  to  some  other  disease  (Noyes). 


226  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Prognosis. — The  disease  tends  to  total  loss  of  sight. 

Treatment. — The  merit  of  having  discovered  that  iridectomy 
is  capable  of  curing  glaucoma,  stamps  the  name  of  Graefe  with 
undying  honor.  Up  to  his  time  no  remedy  was  known,  and  now 
no  remedy,  except  an  operation,  is  of  positive  value,  and  the 
most  favorable  results  are  gained  when  it  is  done  at  an  early 
period.  Acute  attacks  occur  in  chronic  glaucoma,  and  these  are 
controlled  by  combining  a  4  per  cent,  solution  of  cocaine  muri- 
ate with  solution  of  eserine  sulphate  (gr.  i.  to  si. )  Each  may 
be  put  up  in  gelatine  wafers,  and  put  in  the  eye  every  hour. 
Extremely  hot  fomentations  will  give  relief,  and  morphine  may 
be  given  at  night.  Atropia  and  all  mydriatics  should  be  avoided, 
.as  they  tend  to  aggravate  the  symptoms  (Noyes). 

GRANULAR  LIDS.     (See  Trachoma). 

GRAVES'  DISEASE.     (See  Exophthalmic  Goitre). 

GRAVEL.     (See  Calculi  Eenal  ). 

GREENSICKNESS.     (See  Chlorosis). 

GUMMA.     (See  Syphilis). 

GIDDINESS. 

Treatment. — Cod-liver  oil  and  quinine  is  the  best  treatment 
for  giddiness  in  the  aged,  that  is,  when  this  symptom  is  not  as- 
cribable  to  serious  organic  brain  disease,  but  probably  to  ather- 
omatous changes  in  the  brain  vessels,  or  to  a  weak  heart. 

GLANDERS. 

Is  a  contagious  disease  of  horses,  which  may  be  transmitted 
to  man.  The  nodules  of  glanders  are  most  frequently  found  in 
the  nose  of  the  horse,  but  in  this  animal,  as  well  as  in  man,  the 
nodules  may  be  found  in  the  skin,  the  mucous  membranes,  and 
viscera.     The  nodules  usually  suppurate  (Flint). 

Treatment. — There  is  no  drug  which  has  any  influence  on  the 
disease.     Fresh  air,  tonics,  such  as  quinine  and  iron,  should  be 


GLYCOSURIA GOINTAGRA HAEMATEMESIS.  227 

given.  When  the  nose  or  throat  is  the  source  of  trouble,  it 
should  be  washed  with  water  rendered  antiseptic  by  iodine,  car- 
bolic acid,  Condy's  fluid  or  creosote,  nitrate  of  silver  solution, 
tannic  acid,  etc.  Nitro-  muriatic  acid  lotion,  and  a  gargle  of 
chlorate  of  potash  should  be  used  in  the  throat  (Bryant). 

GLYCOSURIA.     (See  Diabetes  Mellitus.) 

GONAGRA.     (See  Gout.) 

MMATEMESIS. 

Is  vomiting  of  blood.  It  is  a  symptom  in  a  variety  of 
diseases.  Rupture  of  a  blood  vessel  is  one  of  its  essential  con- 
ditions. 

Causes. — Injury  to  the  mucous  membrane  of  the  stomach  by 
traumatism  or  poisons,  diseases  of  the  wall  of  the  stomach,  ob- 
struction to  the  portal  circulation,  blood-poisoning,  cancer  and 
ulcer  of  the  stomach,  stoppage  of  the  menses  in  the  female,  and 
sudden  arrest  of  hemorrhoidal  discharges  may  cause  it  (Loomis). 

Symptoms. — If  the  hemorrhage  is  profuse,  the  patient  has  a 
sense  of  heat  and  distention  in  the  epigastrium,  with  nausea  and 
vomiting,  becomes  pale,  has  a  cold  clammy  skin.  If  the  blood  is 
vomited  in  large  quantities  immediately  after  the  bleeding  has 
occurred,  it  will  be  partly  fluid  and  partly  coagulated;  but  if  re- 
tained for  a  time,  it  will  be  fluid  and  have  a  black  or  brownish - 
black  appearance,  with  an  acid  reaction  (Loomis). 

Differential  Diagnosis. — Haemateruesis  may  be  confounded 
with  haemoptysis  or  blood- spitting.  Haemoptysis  is  preceded  by 
bronchial  or  pulmonary  symptoms,  and  haematemesis  by  gastric 
symptoms.  In  haemoptysis  there  is  a  sense  of  constriction  across 
the  chest,  with  dyspnoea  and  cough.  In  haematemesis  there  is 
nausea,  with  a  sense  of  oppression  and  distention  in  the  epigas- 
trium. In  haemoptysis,  blood  is  coughed  up  in  mouthfuls,  bright 
red,  frothy,  alkaline  and  mingled  with  sputa.  In  haematemesis, 
blood  is  vomited  more  or  less  profusely,  is  dark  colored,  mixed 
with  food,  coagulated,  and  often  acid.  In  haemoptysis 
there  is  a  sense  of  trickling  behind  the  sternum,  and  for  a  few 
days  after  the  hemorrhage,  small  blood-spittings  (Loomis). 


228  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Treatment. — During  the  hemorrhage  the  patient  must  be 
kept  absolutely  quiet,  in  a  horizontal  position.  Ice  should  be 
taken  freely,  and  ice-bags  applied  to  the  epigastrium.  Morphine 
and  ergotin  may  be  given  hypodermically.  Brandy  may  be 
given  by  the  rectum  or  hypodermically.  Milk  is  the  only  diet 
allowed  for  the  first  week  (Loomis). 

PRESCRIPTIONS  FOR  H/EMATEMESIS. 

R     Liquor  ferri  subsulphatis §ss. 

Sig.:     One  or  two  drops  in  ice  water  frequently.         — Bartholow. 

R     Ferri  et  ammonii  sulphatis gr.  xL. 

Aqua?  cinnamomi liv. — M. 

Sig. :     A  teaspoonful  every  two  or  three  hours.         — Hartshorne.. 

R     Ergotin gr.  xij. 

Aqua?  destillata? 3j . — M. 

Sig.:     Five  to  ten  minims  hypodermically  every  three  hours. 

— Ringer. 

R     Acidi  gallici gr.  x. 

Acidi  sulphurici  dil XH.  x. 

Aqua?  §j.—  M. 

Ft.  haustus. 
Sig  :     To  be  repeated  in  four  to  six  hours  if  necessary. — Bruton. 

R     Tinctura?  hamamelis §ss. 

Sig. :     Two  to  four  drops  every  two  hours.  — Ringer. 

R     Acidi  tannici 5j- 

Aqua? Sj  • — M. 

Sig.:     A  teaspoonful  frequently.  — Bartholow.. 

HEMATURIA. 

Is  the  passage  of  urine  containing  blood.  The  origin  of  the 
blood  may  be  at  any  point  from  the  meatus  to  the  malpighian 
tuft.     It  is  a  symptom  and  not  a  disease. 

Causes. — Active  and  passive  hyperaemia  of  the  kidney,  acute 
suppurative  nephritis,  tuberculosis  and  stone  in  the  kidney  and 
pyelitis  are  causes.  Turpentine,  cubebs,  copaiba,  cantharides, 
etc.,  may  cause  blood  in  the  urine.  The  causes  in  the  ureter  are 
cancer,  polypi,  ulcers  and  calculi.  The  causes  in  the  bladder  are 
cystitis,   cancer,   abscesses  in  the   wall,   polypi,   stone,  rupture,. 


HEMATURIA.  229 

tuberculosis,  etc.  The  causes  in  the  urethra  are  urethritis,  chor- 
dee,  cancer,  fracture  of  the  penis,  enlarged  prostate,  polypi, 
caustic  injections,  chancre  and  chancroids,  phimosis,  impacted 
stone,  etc.  The  general  causes  of  haematuria  are  acute  infectious 
diseases,  as  fevers,  especially  malarial,  scurvy  and  purpura. 
Haeniaturia  is  endemic  in  some  localities,  as  South  America  and 
Isle  of  France,  due  to  a  parasite  (Loomis). 

Symptoms. — The  urine  may  be  almost  black  and  loaded  with 
clots,  or  it  may  be  only  slightly  smoky  or  pinkish  in  color.  It 
is  albuminous.  The  blood  usually  comes  from  the  urethra,  the 
bladder,  or  the  kidneys.  To  determine  the  source  of  the  blood 
the  following  rules  may  be  observed:  Urethral  hemorrhages  are 
independent  of  micturition,  as  only  a  residue  of  blood  is  washed 
out  at  the  beginning  of  the  flow  of  urine,  and  some  of  the  blood 
will  reach  the  meatus  between  the  acts  of  micturition.  Blood 
effused  into  the  urethra  clots  there  and  assumes  the  shape  of  a 
leech,  and  usually  comes  with  the  first  gush  of  urine.  If  the 
bladder  is  the  source  of  the  hemorrhage,  the  blood  flows  only  at 
the  time  of  micturition,  and  follows  the  discharge  of  urine.  The 
blood  does  not  equally  diffuse  through  the  urine,  so  that  the  first 
passed  is  clear  or  nearly  so,  but  at  the  end  of  the  act  the  urine 
is  much  more  deeply  colored,  or  pure  blood,  in  a  liquid  form,  or 
in  clots  is  voided.  There  is  usually  pain  over  the  bladder,  with 
a  frequent  desire  to  pass  water,  and  a  stoppage  in  doing  so.  In 
renal  hemorrhage,  there  is  pain  in  the  lumbar  region,  and  the 
blood  is  mingled  with  the  urine,  and  is  commonly  as  profuse  at 
the  commencement  as  at  the  end  of  micturition.  Should  blood 
globules,  albumen,  casts,  and  blood  moulded  in  the  form  of  renal 
tubules  be  found  in  the  urine,  renal  disease  may  be  regarded  as 
the  cause  of  the  haematuria. 

Treatment. — When  the  haematuria  is  profuse  or  persistent, 
the  patient  should  be  placed  in  a  recumbent  position,  ice-bags 
applied  over  the  seat  of  the  hemorrhage,  and  haemostatic  reme- 
dies used,  such  as  gallic  or  tannic  acid,  ergot,  acetate  of  lead,  and 
astringent  ferric  preparations  (Loomis). 


230  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  HEMATURIA. 

R     Mucil.  acacise q.  s 

Syrupi  simplicis Siij . 

Olei  gaultherise gtt.  viij. 

Olei  terebinthinse Sss. — M. 

Ft.  emulsio. 
Sig. :     One  to  three  teaspoonfuls  every  three  hours.        — Hunter. 

R     Acidi  gallici  5ss. 

Acidi  sulphurici  dil 5j- 

Tinct.  opii  deodorat 5j- 

Infusi  digitalis 5iv. — M. 

Sig.  •     A  teaspoonful  every  four  hours.  — Druitt. 

R     Tinct.  ferri  muriat XHxxx. 

Tinct.  digitalis 21Tx v. 

Aqua?  menthte  pip siss. — M. 

Ft.  haustus. 
Sig.:     To  be  repeated  every  four  hours.  — Aitkern. 

HEMOPTYSIS. 

Is  the  spitting  of  pure  blood.  The  sputa  are  streaked  with 
blood  in  bronchitis,  intimately  admixed  with  blood  in  pneumonia, 
(the  rusty  colored  matter),  yet  we  do  not  call  this  haemoptysis 
(Loomis). 

Causes. — Pulmonary  congestion,  pulmonary  apoplexy,  and 
inflammation  of  the  lungs  and  bronchi  may  cause  spitting  of 
blood;  but  hemorrhage  from  the  bronchial  tubes  is  by  far  the 
most  frequent  cause  of  blood  spitting  or  haemoptysis.  Ulcera- 
tion, over  distension,  and  weakness  of  the  capillary  walls  of  the 
bronchial  mucous  membrane  are  the  chief  causes  of  bronchial 
hemorrhage.  Bronchial  catarrh,  phthisis,  inhalation  of  irritating 
gases  or  vapors,  passive  hyperemia  of  the  lungs  from  obstructive 
heart  disease,  intense  active  hyperaemia,  the  violent  coughing  of 
bronchitis,  pertussis,  and  pneumonia,  and  suppression  of  the 
menses  may  cause  it.  Ulceration  of  an  exposed  vessel  in  ad- 
vanced phthisis  will  cause  it  (Loomis). 

Symptoms. — All  bronchial  hemorrhages  are  attended  by  the 
spitting  of  bright  red,  frothy,  arterial  blood.  They  may  come 
on  suddenly  without  any  warning,  but  usually  there  is  a  sense  of 


HAEMOPTYSIS.  231 

constriction  at  the  upper  portion  of  the  chest.  Cough  may  or 
may  not  precede  the  hemorrhage.  Usually  the  patient  feels  as 
if  some  fluid  had  suddenly  commenced  trickling  under  the  ster- 
num, and  he  notices  an  unusually  sweetish  or  saltish  taste  in  the 
mouth.  The  blood  in  the  throat  brings  on  fits  of  coughing. 
Blood  may  be  expectorated  only  for  a  few  hours,  or  for  several 
days.  The  amount  varies  from  an  ounce  to  a  pound.  The 
patient  has  an  anxious  expression,  becomes  tremulous  and  often 
faints.  Hemorrhage  from  the  lungs  weakens  a  patient.  The 
patient  goes  on  coughing  for  a  few  days,  expectorating  small 
dark  coagulated  masses  of  blood,  or  blood- streaked  sputa. 

Sometimes  the  hemorrhage  is  so  profuse  that  the  blood 
spouts  out  at  the  mouth  and  nose,  and  this  points  to  rupture  of 
an  aneurism  (Loomis). 

Differental  Diagnosis. — Haemoptysis  may  be  confounded  with 
epistaxis,  pulmonary  apoplexy,  hseinateniesis,  and  aneurisms 
rupturing  into  the  air  passages. 

In  epistaxis,  the  blood  is  always  coagulated  and  dark-  colored. 
It  is  not  attended  or  ^followed  by  a  cough,  and  blood  can  always 
be  detected  in  the  nostrils  and  posterior  nares. 

In  hgematemesis,  the  blood  is  black,  contains  no  air,  has  an 
acid  reaction,  is  mixed  with  articles  of  food,  and  is  vomited;  in 
haemoptysis  the  blood  is  bright  red,  contains  air,  has  an  alkaline 
reaction,  and  is  coughed  up,  while  there  is  no  nausea.  When  an 
aneurism  ruptures  into  a  bronchial  tube,  the  hemorrhage  is  gen- 
erally profuse,  and  it  is  soon  followed  by  death.  The  blood 
spurts  out  in  jets.  There  is  a  history  of  aneurism.  If  the  blood 
comes  from  the  mouth  or  fauces  close  inspection  will  reveal  the 
fact. 

Haemoptysis  should  always  excite  a  strong  suspicion  of  tub- 
erculous disease  (Loomis  and  Flint). 

Prognosis. — As  to  final  result  is  always  unfavorable,  but 
haemoptysis  rarely  proves  immediately  fatal  (Loomis). 

Treatment. — Absolute  rest  in  a  cool  room,  with  the  patient 
in  bed  and  not  allowed  to  sit  up,  turn  over,  or  even  speak  above 
a  whisper,  is  of  the  greatest  importance.  If  the  cough  continues, 
full  doses  of  opium  must  be  given.  Ergot,  tannin,  gallic  acid, 
acetate  of  lead,   spirits   of  turpentine,  persulphate   of   iron,   or  a 


232  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

mouthful  of  common  salt  may  be  administered.  When  the  pulse 
is  full  and  strong  Loomis  uses  aconite;  when  it  is  weak,  he  em- 
ploys morphia  hypoderniically.  Ice -hags  may  be  applied  to  the 
chest,  and  the  patient  urged  to  eat  ice,  and  drink  freely  of  cold 
drinks.  Counter  irritants  are  serviceable,  such  as  mustard  plas- 
ter, nvino-  blister,  or  turpentine  (Loomis  and  Flint). 

PRESCRIPTIONS  FOR  HEMOPTYSIS, 

JJr     Extracti  ergotse  fid 5J. 

Olei  gaultherise gtt.  iv. — M. 

Sig. :     A  teaspoonful  every  hour  at  first ;  then  every  four  to  six 
hours.  —Ringer. 

J&     Infusi  digitalis §iv. 

Sig.:     A  tablespoonful  every  hour  until  the  pulse  is  reduced. 

— Brinton. 

{Jr     Sodii  chloridi §ij. 

Sig.:     Take  half  teaspoonful  dry.     Repeat  till  nausea  occurs. 

— Ringer. 

fy     Pulv.  aluminis 3j. 

Sacchari  albi 3!?s. 

Pulv.  ipecac  comp gr.  xx. — M. 

In  pulv.  no.  vi.  div. 
Sig.:     One  powder  every  two  hours.  — Skoda. 

J&     Plumbi  acetatis gr.  xx. 

Pulv.  digitalis gr.  x. 

Pulv.  opii gr.  v.— M. 

Ft.  massa  et  in  pil  no.  x.  div. 
Sig.:     One  pill  every  four  hours.  — Bartholow. 

HAY=FEVER, 

Called  also  summer  catarrh,  hay-asthma,  rose-cold,  June- 
cold  and  autumnal  catarrh,  is  an  acute  catarrh  of  the  upper  air 
passages  chiefly,  occurring  at  a  fixed  period  annually,  and  disap- 
pearing after  a  variable  duration  (Bartholow). 

Causes. — Emanations  from  roses,  and  new  mown  hay,  or 
grasses,  and  the  pollen  of  wheat,  rye,  oats  and  barley  may  excite 
the  disease.  When  the  neurotic  temperament  is  present  and  a 
special  tendency  exists,  various  exciting  causes,  as  heat,  dust,  etc., 
may  excite  summer  catarrh  (Bartholow). 


HAY -FEVER.  233 

Symptoms. — There  are  two  forms  in  which  the  disease  mani- 
fests itself — the  catarrhal  and  the  asthmatic.  Hay-fever  is  dis- 
tinctly periodical.  It  occurs  at  certain  seasons  only.  In  the 
catarrhal  form,  the  onset  is  sudden  in  the  majority  of  cases.  The 
first  symptom  is  an  itching  of  the  eyes,  nose,  behind  the  posterior 
nares,  and  the  palate.  This  is  followed  by  the  now  of  a  trans- 
parent serous  fluid,  and  then  sneezing  begins.  Henry  Ward 
Beecher,  himself  a  sufferer  from  the  disease,  describes  the  sneez- 
ing as  follows:  "You  never  before  even  suspected  what  it  really 
was  to  sneeze.  If  a  pane  of  glass  is  gone,  you  sneeze.  If  you 
look  into  the  sunshine,  you  sneeze.  If  you  sneeze  once,  you 
sneeze  twenty  times.  It  is  a  riot  of  sneezes.  First  a  single  one, 
like  a  leader  in  a  flock  of  sheep,  bolts  over;  and  then,  in  spite  of 
all  you  can  do,  the  whole  flock,  fifty  by  count,  come  clashing  over 
in  twos,  in  fives,  in  bunches  of  twenty."  The  eyes  water,  and 
the  conjunctiva  reddens;  the  nasal  mucous  membrane  swells  and 
becomes  hypersernic;  the  breathing  is  carried  on  by  the  mouth. 
There  is  a  sense  of  heat  and  burning  in  the  nose  and  eyes,  and 
pain  shoots  through  the  orbits.  The  throat  is  hot,  dry  and 
swollen. 

In  the  asthmatic  form,  the  larynx  and  bronchial  tubes  are 
swollen  and  hypersemic.  There  is  a  croupy,  or  a  wheezy  bron- 
chial cough.  The  patient  is  unable  to  lie  down,  struggles  for 
breath,  is  pale,  and  covered  with  a  cold  sweat. 

The  duration  of  hay-fever  is  from  a  few  days  to  three 
months,  the  average  being  about  six  weeks  (Bartholow). 

Treatment. — There  is  no  remedy  so  effectual  as  removal  from 
the  hay  fever  zone  in  time  to  prevent  the  attack.  The  patient 
may  be  exempt  from  the  attack  if  on  the  ocean.  The  White 
Mountains,  the  Catskills,  the  Adirondacks,  the  Rocky  Moun- 
tains, and  the  highest  points  of  the  Alleghenies,  and  many 
places  by  the  seashore  can  be  resorted  to  with  confidence  of  re- 
lief. Quinine  has  been  more  useful  than  any  other  agent,  and 
should  be  given  in  five  grain  doses  three  times  a  day  for  a  week 
before  the  attack,  and  when  the  first  symptoms  of  irritation  of 
the  nares  are  felt,  a  solution  of  the  muriate  should  be  applied  to 
the  nares. 


234  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

When  the  disease  has  begun,  the  best  results  are  obtained 
from  fifteen  grain  doses  of  iodide  of  potassium  every  four  to  eight 
hours.  Morphine  gr  £  and  atropine  gr  2w  are  good  when  there 
is  much  secretion.  Local  applications  are  more  effectual  than 
internal  remedies. 

R     Acidi  carbolici ^iij. 

Tinct.  iocli 3v. — M. 

Sig. :     Add  from  one  to  five  minims  to  a  gill  of  water,  and   apply 
to  the  nose  by  means  of  a  syringe. 

A  few  drops  of  the  tincture  of  iodine  may  be  placed  in  a 
warm  vial,  and  cautiously  inhaled. 

Cocaine  in  solution  or  in  the  form  of  a  pellet  placed  along- 
side the  septum  and  allowed  to  dissolve  slowly,  has  proved  to  be 
the  most  effective  agent  for  affording  relief.  The  dose  will  be 
$■-£  gr  (Bartholow). 


e> 


PRESCRIPTIONS  FOR  HAY=FEVER. 

R     Cocaine  muriatis gr.  v. 

Aquae  destillatse oij- — M. 

Sig.:  Apply  to  nasal  passages  with  a  camel's  hair  brush. — Sajous. 

R     Syrupi  acidi  hydriodici §iv. 

Sig. :     A  teaspoonful  every  two  hours.  — Judkins. 

R     Quinine  muriatis gr.  iv.-viij. 

Aqua? gj . — M. 

Sig.:     Apply  to  the  nares  with  an  atomizer.  — Bartholow. 

R     Antipyrin 5ss. 

Syrupi  aurantii  cort Bj. 

Aqua; ad §iij. — M. 

Sig.:     A  teaspoonful  one  to  three  times  a  day.  — Cheatham. 

HEADACHE. 

Called  also  cephalalgia,  is  properly  a  form  of  neuralgia,  as 
it  can  only  be  referred  to  the  sensory,  nerves  supplying  the  men- 
inges and  scalp.  It  is  a  symptom  occurring  in  many  affections, 
such  as  active  cerebral  congestion,  cerebral  meningitis,  the  essen- 
tial fevers,  acute  dyspepsia,  syphilitic  periostitis  of  the  head,  in- 
tracranial   tumors,    etc.     Headache    is    extremely    common.     It 


HEADACHE. 


235 


occurs  in  paroxysms,  lasting  usually  from  twelve  to  twenty-four 
hours  (Loomis  and  DaCosta). 

Varieties. — 1.  Congestive.  2.  Astigmatic.  3.  Headache  from 
poisoning.  4.  Headache  in  diseases  of  the  brain.  5.  Nervous, 
or  neuralgic.  6.  Sick-headache.  7.  Sympathetic.  8.  Uraemic. 
9.  Anaemic  (DaCosta). 

Causes. — An  optical  defect,  as  hyperopia,  or  astigmatism  may 
cause  an  intense  headache.  A  severe  headache  may  be  depend- 
ent upon  decayed  teeth,  and  will  disappear  with  their  removal. 
In  acute  inflammation  of  the  brain,  the  pain  is  agonizing  and 
continuous,  and  is  associated  with  fever,  vomiting  and  delirium. 
In  abscess  of  the  brain,  and  in  softening,  the  headache  is  less 
violent,  and  is  accompanied  by  signs  of  disturbed  intellection 
and  of  deranged  motion.  In  tumor  of  the  brain,  the  headache 
is  apt  to  be  severe  and  paroxysmal,  but  intellection  is  not  at 
first  much  affected. 

In  congestion  of  the  brain  the  pain  is  dull,  increased  by 
stooj)ing  or  lying  clown,  by  long  sleep,  and  by  bodily  or  mental 
fatigue,  with  flushed  face  and  throbbing  of  the  arteries  of  the 
neck.  A  form  of  congestive  headache,  apt  to  be  relieved  by 
bleeding  at  the  nose,  is  often  seen  in  young  people  at  the  age  of 
puberty;  the  attacks  are  brought  on  by  running  or  other  violent 
exercise. 

In  diseases  of  the  meninges,  the  pain  is  constant  and  fixed, 
and  sometimes  very  sharp. 

Nervous  or  neuralgic  headache  is  most  common  in  women, 
especially  in  anaemic  women.  It  is  very  severe,  yet  of  short 
duration. 

Sympathetic  headache  is  found  mainly  in  connection  with 
disorders  of  the  alimentary  tube,  and  of  the  uterus,  and  is  often 
worse  in  the  morning,  before  food  has  been  taken.  Headache 
may  be  dependent  upon  various  poisons,  as  in  Bright's  disease, 
the  retention  of  a  large  quantity  of  urea  in  the  blood  becomes 
the  source  of  persistent  pain  in  the  head.  Headache  is  common 
in  lead  poisoning,  in  opium-eaters,  in  drunkards,  and  after  the 
use  of  strychnine  and  quinine.  Headache  increased  by  the  erect 
posture  and  relieved  by  lying  down  bespeaks  an  anaemic  condi- 
tion of  the  brain.     Sick-headache,  or  hemicrania,  or  migraine,  or 


236  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

megrim,  lias  symptoms  which  set  it  apart.  The  pain  is  usually 
attended  by  nausea  and  vomiting,  is  generally  at  first  one-sided, 
and  the  patient  vomits  bile  (DaCosta).  The  vomiting  often 
ends  the  attack.  The  face  is  flushed  and  red  and  light  is  hurtful 
to  the  eyes.  The  paroxysms  may  last  for  a  few  hours,  or  a  day 
or  two.  Women  are  especially  liable  to  attacks  about  the  men- 
strual period.  Attacks  may  occur  every  few  days,  every  week, 
or  every  month,  and  in  many  they  are  induced  by  errors  of  diet. 
They  usually  disappear  after  the  age  of  fifty. 

Headache  of  gastric  or  hepatic  origin  is  commonly  frontal 
and  throbbing  in  character.  Headache  at  the  vertex  is  symp- 
tomatic of  cerebral  disturbances,  or  it  is  due  to  reflex  irritation, 
starting  in  the  pelvic  organs  of  the  female.  Pain  in  the  occipital 
region  is  mostly  an  accompaniment  of  disorders  of  circulation, 
and  vaso  motor  spasm  and  anaemia  in  particular.  The  pain  of 
cerebral  compression,  or  tumor,  is  generally  localized,  persistent, 
and  very  intense  (Loomis  and  Bartholow). 

Treatment. — In  anaemic  headache  the  inhalation  of  nitrite  of 
amyl  is  serviceable.  In  congestive  headache,  ergot  affords  relief. 
The  bromides  and  hydrate  of  chloral  are  sometimes  efficacious. 
The  inhalation  of  a  little  chloroform  is  sometimes  efficient. 
Evaporating  lotions  to  the  head — alcohol,  spirits,  vinegar,  or 
ether — in  some  cases  afford  marked  relief.  Hot  water  to  the 
head  sometimes  relieves.  Strong  coffee  or  tea  affords  marked 
relief  in  some  cases.  The  faradic  and  galvanic  currents  may  be 
tried.  During  the  intervals,  nux  vomica  in  small  doses,  arsenic, 
or  small  doses  of  quinia  may  be  tried.  The  hypophosphites  and 
cod-liver  oil,  continued  steadily  for  months,  have  done  good  in 
debilitated  subjects.     Tobacco  smoking  should  be  prohibited. 

PRESCRIPTIONS  FOR  HEADACHE. 

R     Potassii  citratis gr.  xx 

Spiritus  juniperi 3j- 

Spts.  aatheris  nitrosi 21  (xx. 

Infusi  scoparii oj- — M. 

Sig.:     To  be  taken  thrice  daily.     (Ureemic  form.)   — W.  H.  Day. 

R     Potassii  acetatis 5yj. 

Infusi  digitalis Svj. — M. 

Sig. :     A  tablespoonful  every  third  hour.     (Urcemic  headache.) 


HEART    BURN HEMICEANIA HEMIPLEGIA.  237 

R     Gran,  efferv.  bromo  caffeine Siv. 

Sig. :    A  teaspoonful  in  half  glass  of  water — cold.    Repeat  in  half 
an  hour  if  necessary.     (Nervous  form.)  — R.  V.  Mattison. 

R     Zinci  phosphidi • gr.  iij. 

Ext.  nucis  vomica? gr.  x. 

Confect.  rosse q.  s — M. 

Ft.  massa  et  in  pil.  no.  xxx.  div. 
Sig. :     One  after  each  meal.     (Nervous  form.)     — Fordyce  Baker. 

HEART  BURN.     (See  Acidity.) 

HEMICRANIA.     (See  Headache.) 

HEMIPLEGIA.     (See  also  Paralysis.) 

Is  a  motor  paralysis  of  one  side  of  the  body.  It  is  generally 
the  result  of  the  lesion  above  the  medulla,  and  most  frequently 
of  the  corpus  striatum,  but  may  result  from  injury  to  a  cerebral 
hemisphere  or  crus.  It  occurs  on  the  side  opposite  to  the  dis- 
ease or  injury.     (Loomis). 

Causes. — Its  most  frequent  cause  is  apoplexy,  but  it  may  be 
due  to  other  cerebral  injuries  or  disease,  and  is  frequently  func- 
tional. The  cerebral  causes  are  :  Compression  from  bone,  blood, 
pus,  or  inflammatory  exudations,  tumors,  especially  carcinoma 
sarcoma  and  gummata.  Partial  anaemia  from  thrombosis,  embol- 
ism, softening,  aneurism  and  apoplexy.  Encephalitis,  abscess, 
atrophy  and  sclerosis. 

The  spinal  causes  are  as  above,  or  any  disease  affecting  a, 
lateral  half  of  the  cord. 

The  functional  causes  are  :  Hysteria,  chorea,  epilepsy,  diph- 
theria, malaria,  poisons,  etc.  The  muscles  of  the  arm  and  leg  are 
chiefly  affected,  while  those  of  the  trunk  and  neck  often  escape 
entirely.  Of  the  cranial  nerves  the  third,  fourth,  fifth,  sixth  and 
seventh  and  twelfth  may  suffer.  If  the  fifth  nerve  suffers  there 
will  be  anaesthesia  of  the  face  and  cornea  and  paralysis  of  the 
muscles  of  mastication  on  the  affected  side.  If  the  facial  nerve 
suffers,  the  face  becomes  a  blank  and  motionless,  and  the  mouth 
is  drawn  toward  the  healthy  side.  If  the  twelfth  nerve  suffers 
the  tongue  will  then  be  protruded  with  the  tip  pointed  toward 
the  affected  side.     The  history  of  the  case,  the  matter    of  inva- 


238  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

sion,  and  other  symptoms,  will  usually  give  a  clue  to  the  location 
of  the  lesion. 

It  has  been  noticed  that  paralysis  caused  by  lesions  in  the 
motor  tract  above  the  ganglionic  cells  in  the  anterior  cornua  of 
the  cord  is  seldom  followed  by  much  muscular  atrophy  or  more 
than  would  be  caused  by  inactivity,  while  disease  affecting  these 
cells  or  the  peripheral  nerve -trunks  produces  marked  muscular 
atrophy  as  well  as  paralysis  (Loomis). 

Hemiplegia  may  be  feigned:  but  the  results  of  electricity, 
and  the  test  proposed  by  Hughlings  Jackson,  that  the  arms  do 
not,  as  in  real  hemiplegia,  fall  forward  when  the  patient  stoops, 
but  are  retained  at  the  side,  will  usually  detect  the  fraud  (Da 
Costa). 

Treatment. — In  hemiplegia  the  constant  current  may  be  ap- 
plied to  the  brain,  for  the  purpose  of  improving  its  nutrition, 
and  the  faradic  current  to  the  muscles,  to  prevent  wasting  and 
loss  of  function  from  disease.  In  faradizing  the  muscles  in  a 
case  of  hemiplegia,  a  current  of  just  sufficient  intensity  to  cause 
contractions  should  be  used.  The  hypodermatic  injection  of 
strychnine  into  the  paralyzed  muscles,  after  the  local  troubles 
have  ceased,  is  very  efficacious.  In  hemiplegia  and  other  forms 
of  paralysis  due  to  intracranial  lesions,  the  indications  for  the 
treatment  by  massage  are  a  lowered  state  of  the  nutrition  of  the 
paralyzed  parts,  coldness  and  blueness  of  the  skin,  wasting  and 
contracted  muscles,  ulcerations,  etc  (Bartholow). 

HEART  DISEASES.     (See  each  particular  affection). 

Treatment  in  General. — Overaction  of  the  heart,  Avith  hyper- 
trophy, and  without  valvular  lesion,  is  benefited  by  a  quantity 
of  aconite  sufficiently  large  to  moderate  the  cardiac  movements 
(Bartholow). 

In  simple  hypertrophy  of  the  heart,  without  valvular  lesion, 
the  tincture  of  veratrum  viride  diminishes  the  overaction  and 
gives  relief.  The  irritable  heart  dependent  on  the  excessive  use 
of  tobacco,  on  mental  excitement,  and  on  overstrain,  is  relieved 
by  five  drops  of  the  tincture  of  veratrum  viride  three  times  daily 
(Bartholow).  Digitalis  is  indicated  when  the  action  of  the 
heart  is  rapid  and  weak,  and  the  arterial  tension  low. 


HEART    DISEASES — HEMORRHAGES.  239 

|fc     Extracti  ergotae  fluidi siiiss. 

Tincturse  digitalis §ss. — M. 

Sig. :     A  teaspoonfal  three  times  a  day.    (In  enlarged  heart  with- 
out valvular  lesion).  — Bartholow. 

{fc     Ferri  redacti 

Quininae  sulphatis 

Pulveris  digitalis  (English). ...aa...gr.  xx. 

Pulveris  scillae gr.  x. — M. 

Ft.  pil.  no.  xx. 
Sig. :     One  pill  three  or  four  times  a  day.     (In  irritable  heart  of 
anaemia  and  chlorosis,  and  in  fatty  heart).  — Bartholow. 

In  dilated  heart,  with  difficult  breathing,  and  general  oedema, 
the  hypodermic  injection  of  morphine,  the  eighth  to  the  sixth  of 
a  grain,  two  or  three  times  a  week,  possesses  a  high  degree  of 
utility  (Bartholow). 

To  stimulate  the  action  of  the  heart  when  it  flags,  the  am- 
monia 23reParations  have  an  undoubted  effect.  It  is  a  most 
common  practice  to  inhale  ammonia  to  prevent  that  depression 
of  the  heart's  action  called  fainting  (Bartholow). 

|fc     Cocaini  hydrochloratis gr.  yj. 

Aquae  destillatae §iij. — M. 

Sig. :     A  teaspoonful  three  times  daily.     (In  nervous  cardiac  de- 
bility). — Rosenbach. 

|&     Tincturse  digitalis 5ij. 

Spiritus  chloroformi 5 v. 

Infusi  buchu ad  3xij. — M. 

Sig.:     Two  tablespoonfuls  in  a  wineglassful  of  water  three  times 
daily.     (In  simple  cardiac  debility).  — Fothergill. 

Jfc     Strychnia?  sulphatis gr.  j. 

Aquae  3J. — M. 

Ft.  sol. 
Sig. :     Eight  to  fifteen  minims  hypodermically.    (For  exhausted 
heart  muscle  and  its  nerves).  — Habershon. 

{&     Vini  cocae  Mariani 0.  j. 

Sig.:     A  wineglassful  three  or  four  times  daily     (In  overstrain  of 
heart). 

HEMORRHAGES. 

Treatment. — Digitalis  has  an  undoubted  power  to  arrest 
hemorrhage.      The  mechanism  of  its  action  is  similar  to  that  of 


240  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ergot;    it  slows  the  action   of  the  heart  and   contracts   the  arte- 
rioles. 

R     Infusi  digitalis §ij- 

Tincturse  kramerise 

Ext.  ergotse  fluidi aa  §j. — M. 

Sig. :     A  tablespoonful  pro  re  nata.  — Bartholow. 

Active  hemorrhage,  occurring  in  the  plethoric,  is  sometimes 
stopped  by  full  medcinal  doses  of  veratrum  viride  (tincture 
XII  v).  The  value  of  acetate  of  lead  in  various  forms  of  hem- 
orrhage has  been  attested  by  an  immense  clinical  experience.  In 
haemoptysis  and  haeinatemesis  it  is  a  most  useful  haemostatic, 
given  in  live  grain  doses  every  three  hours.  Chloride  of  barium 
in  close  of  gr.,  1-10-gr.,  ss.  has  proved  very  useful  in  hemorrhage. 
Ipecac  is  a  most  valuable  remedy  in  haemoptysis,  epistaxis,  men- 
orrhagia,  postpartum  hemorrhages,  etc.  It  arrests  all  kinds  of 
hemorrhage,  and  should  be  given  in  frequently  repeated  doses 
until  vomiting  occurs. 

R     Extracti  ipecac    fluidi sij. 

Extracti  ergotse   fluidi giv. 

Extracti  digitalis  flcl 3ij— M. 

Sig.:     Thirty  minims  to  a  teaspoonful  at  a  dose  as  required. 

— Bartholow. 

The  fluid  extract  of  ergot  will  often  arrest  the  bleeding  of 
hemorrhoids  and  cause  such  a  contraction  of  the  vessels  in  recent 
cases,  as  that  the  symptoms  may  entirely  disappear.  Ergot  is 
used  in  various  forms  of  hemorrhage.  It  is  used  in  epistaxis, 
haemoptysis,  renal,  intestinal  and  uterine  hemorrhage.  One  to 
two  drachms  of  the  fluid  extract,  given  every  half  hour  or  hour, 
will  be  necessary  in  urgent  cases.  In  haemoptysis  the  ergot  may 
be  given  as  follows  : 

R     Extracti  ergotse  fluidi Siij. 

Extracti  ipecac  fluidi. 

Tinct.  opii  deodorat  aa sss. — M. 

Sig.:     A  teaspoonful  every  half  hour  or  hour.  — Bartholow. 

In  renal  hemorrhage,  the  following  is  useful: 

R     Extracti  ergota?  fluidi 

Tincturse  kramerise — aa Sij  • — M. 

Sig.:     A  teaspoonful  every  hour  or  two.  — Bartholow. 


HAEMORRHAGE.  241 

In  passive  haemorrhages,  the  following  is  useful: 

R     Olei  terebinthinse siij. 

Extracti  digitalis  fid 5j. 

Mucil  acacias Sss. 

Aquas  menthse  pip Sj. — M. 

Sig. :     A  teaspoonful  every  three  hours.  — Bartholow. 

The  following  mixture  is  very  effective  in  menorrhagia,  hae- 
maturia,  purpura  haemorrhagica  and  the  hemorrhagic  diathesis: 

R     Acidi  gallici 5ss. 

Acidi  sulph.  dil 5j- 

Tincturse  opii  deodor 5j. 

Infusi  rosse  comp Siv. — M. 

Sig.:     A  tablespoonful  every  four  hours  or  oftener. — Bartholow. 

Astringents,  such  as  alum,  acetate  of  lead,  iron  subsulphate 
and  chloride,  sulphuric  acid,  tannin,  gallic  acidi  and  the  vegeta- 
ble astringents  are  employed  locally  and  systemically  in  the 
various  kinds  of  haemorrhage.  When  the  blood  pressure  is  high 
and  cerebral  haemorrhage  threatened  or  proceeding,  venesection, 
or  leeches,  or  purgatives  (saline)  are  the  most  effective. 

In  uterine  haemorrhage,  full  doses  of  the  fluid  extract  of 
ergot  will  give  good  results.  Ipecac  carried  to  nausea  merely  is 
highly  effective.  Digitalis  and  sulphuric  acid  diluted  in  small 
doses  frequently  repeated  are  highly  serviceable. 

Monsel's  solution  one  part  and  water  three  parts  may  be 
injected  into  the  uterine  cavity  to  arrest  bleeding,  if  the  os  is 
patulous  (Bartholow). 

PRESCRIPTIONS  FOR  HEMORRHAGE. 

R     Argenti  nitratis  fusae q.  s 

Sig.:     Wipe  the  wound  dry,  and  apply  locally.     (In  leech-bites.) 

— Ringer. 
R     Acidi  acetici  dil Svj. 

Sig.:     Apply  locally.     (For  leech-bites,  piles,  cuts.)        — Ringer. 

R     Tinctune  opii 5j- 

Spts.  vini  gallici oj- — M. 

Ft.  haustus. 
Sig. :     To  be  taken   at  once.     (In  flooding  after  delivery,  with 
uterine  exhaustion.)  — Ringer. 


242  A    COMPENDIUM    OF    PRACTICAL     MEDICLffE. 

R     Tincturse  hsemamelis Siv. 

Sig. :     Use  pure  or  diluted.     (In  cuts,  leech-bites,  oozing  from 
wounds,  etc.)     Also  internally  three  minims  every  three  hours. 

— Ringer. 

HEMORRHOIDS,  OR  PILES. 

Are  small  tumors  at  the  anal  verge.  Kinds,  bleeding  and 
non- bleeding.  The  bleeding  piles  are  generally  the  internal, 
and  composed  of  a  highly  vascular  tissue  involving  the  mucous 
membrane  of  the  rectum  and  the  submucous  tissue  with  enlarged 
arteries  and  veins.  If  the  artery  is  enlarged  the  tumor  has  a 
bright-red  aspect  and  is  called  the  strawberry  pile.  If  the  vein 
is  enlarged,  the  tumor  has  a  dusky  hue. 

The  non- bleeding,  or  external  piles,  are  composed  of 
loose  folds  of  the  skin  that  surround  the  anus,  or  a  varicose,  in- 
flamed or  ruptured  vein.  The  treatment  of  external  piles  is 
simple,  and  excision  is  the  only  radical  cure. 

In  the  earlv  stagre  of  the  affection  local  cleanliness,  and  ab- 
stinence  fi'om  highly  seasoned  food  and  strong  wines,  are  mostly 
sufficient.  The  bowels  must  be  kept  clear.  When  local  irrita- 
tion exists,  an  ointment  of  zinc  and  the  extract  of  belladonna  is 
very  useful  (Bryant ). 

Causes. — Constipation,  sedentary  habits  or  occupations,  and 
high  living  appear  to  have  the  strongest  influence.  Pregnancy 
and  abdominal  tumors  are  causative.  Internal  piles  are  very 
insidious  in  their  growth — bleeding  is  often  the  first  symptom 
that  attracts  attention. 

Treatment. — Is  both  medicinal  and  surgical.  All  piles  do 
not  require  removal.  The  medical  or  palliative  treatment  of 
piles  means  attention  to  diet,  the  giving  up  of  high  living  and 
strong  drinks,  and  the  taking  of  simple,  nutritious  food  in  mod- 
eration. The  bowels  should  be  kept  open  by  purgatives,  or 
enema.  Absolute  local  cleanliness  should  always  be  observed. 
Bv  these  different  means  an  attack  of  piles  may  pass  away  never 
to  return.  "When  the  piles  are  inflamed,  hot  or  cold  applications 
are  useful. 

Surgical  Treatment. — Unless  the  general  condition  of  the 
patient  forbids,  all  piles,  external  or  internal,  should  be  removed. 
External   piles   ought  to  be   removed   by  abscission.     Internal 


HEMOEETIOIDS.  243 

piles  ouglit  never  to  be  excised,  but  destroyed  by  the  galvanic  or 
actual  cautery,  crushing,  or  the  ligature.  In  Paris  a  plan  of 
treatment  has  been  successful  which  consists  of  forced  anal  dila- 
tation, either  by  the  thumbs,  or  by  means  of  a  dilator,  the  piles 
withering;  after  one  full  dilatation  of  the  anus. 

The  Ligature  Method. — The  surgeon  grasps  the  base  of  the 
pile  to  be  ligatured  by  a  pair  of  forceps,  and  separates  the  pile 
from  the  skin  and  submucous  tissue  by  scissors,  and  then  trans- 
fixes it  with  a  needle  armed  with  a  double  silk  ligature.  He 
should  then  divide  the  cord  and  tie  the  pile  tightly  in  halves,  and 
cut  off  half  of  the  strangulated  portion.  The  other  masses  are 
treated  similarly.  The  ligatures  slough  off  about  the  seventh  or 
tenth  day. 

After  Treatment. — After  the  operation  an  opiate  may  be 
given.  The  bowels  should  be  left  undisturbed  for  two  days, 
when  a  dose  of  castor- oil  or  enema  may  be  given.  If  oedema  of 
the  parts  follow,  ice  may  be  applied  or  a  lotion  of  lead  and 
opium. 

The  Cautery  Method. — The  galvanic  cautery  is  preferable  to 
the  actual.  The  anus  is  to  be  forcibly  dilated,  and  each  mass  is 
then  to  be  seized  in  turn  by  a  clamp,  and  the  projecting  half  of 
each  mass  must  then  be  cut  off  with  scissors,  the  surface  wiped 
dry,  and  the  cautery,  heated  to  a  white  heat,  applied  to  the  sur- 
face, the  whole  projecting  portion  being  burned  down  to  a  level 
of  the  clamp.  The  clamp  should  be  removed  so  as  not  to  dis- 
turb the  eschar.  When  all  the  jnles  have  been  treated,  the 
whole  projecting  mass  may  be  returned  into  the  rectum  with  the 
fingers  well  greased,  and  a  suppository  of  opiuin  or  morphine  in- 
troduced at  this  time  to  soothe  the  pain.  The  after  treatment  is 
the  same  as  in  ligature. 

Treatment  by  Crushing. — A  clamp,  is  to  be  adjusted  as  in 
the  operation  for  cautery,  and  the  protruding  pile  cut  off  with 
scissors.  The  clamp  which  is  very  strong,  is  left  on  the  pile  for 
one  minute. 

Treatment  by  the  Subcutaneous  Injectfon  of  Carbolic  Acid. — It  is 
applicable  to  internal  piles  alone,  and  one  pile  should  be  treated  at  a 
time,  about  a  week  being  allowed  between  the  operations.  About 
one  to  six  drops,  of  a  solution  of  carbolic  acid  in  thirty  of  olive 


244  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

oil  or  glycerine  should  be  injected  with  a  hypodermic  syringe 
into  the  pile,  which  turns  white,  and  in  successful  cases  withers 
without  pain  or  sloughing. 

Dr.  A.  A.  Smith  of  Xew  York,  gives  the  following: 

R     Acidi  carbolici gr.  vj. 

Cocaini  hydrochloratis gr.  x. 

Glycerini giij . — M. 

Sig..     Inject  ten  minims  into  the  tumor  or  pile. 

When  a  fissure  or  painful  ulcer  coexists  with  hemorrhoids,. 
its  base  should  be  lacerated  by  forcible  dilatation  of  the  anus. 

In  operating  on  piles  the  surgeon  must  be  careful  not  to 
take  away  too  much  tissue.  In  rectal  operations,  it  is  probably 
advisable  to  use  anaesthetics  in  all  cases  (Bryant). 

PRESCRIPTIONS  FOR  HEMORRHOIDS. 

R     Ferri  sulph gr.  xx. 

Pulv.  aloes  Soc 

Extracti  opii  aq  

Sapo  cast aa gr.  x. — M. 

Ft.  pil.  no.  xx. 
Sig.:     One  pill  morning  and' evening:  — Fordyce  Baker. 

R     Tincturae  nucis  vomica? 3j. 

Ext.  ergotaefld Jj.—  M. 

Sig. :     A  teaspoonful  three  or  four  times  a  da}'.  (For  bleeding 

piles  and  post  partum  piles).  — Bartholow. 

R     Tinct.  hamamelis §iv. 

Sig.:  One-half  to  one  teaspoonful  in  an  ounce  of  cold  water,  in- 
jected into  the  rectum  daily  before  rising.  Also  take  internally  two 
to  five  minims  three  times  daily.  — Ringer. 

R     Acidi  nitrici Bss.-j. 

Aqua? iviij. — M. 

Ft,  lotio. 
Sig.:     Apply  as  a  wash.     (In  bleeding  piles).  — Ringer. 

HEPATITIS.     (Interstitial).     (See  Cirrhosis). 

HEPATITIS.     (Circumscribed  Suppurative.) 

Is  an  abscess  of  the  liver. 

Causes. — Pysemic  infarction,  phlebitis,  the  result  of  opera- 
tions on  the  intestines  (as  for  prolapsus   ani,   hemorrhoids,  and 


HEPATITIS HERPES.  245 

strangulated  hernia),  and  intestinal  traumatism,  may  give  rise  to 
abscess  of  the  liver.  Hot  climates,  miasmatic  influences  and 
dysentery  are  regarded  as  causes  of  abscess  of  the  liver.  Ulcera- 
tion of  the  stomach,  of  the  intestine,  gall-bladder  and  appendix, 
ulcerative  endocarditis,  and  cancer  of  the  stomach  are  often 
associated  with  abscess  of  the  liver.  Obstruction  to  the  common 
duct,  by  worms  or  calculi  may  lead  to  ulceration  followed  by 
abscess  of  the  liver  (Loomis). 

Symptoms. — A  slight  feeling  of  chilliness,  sometimes  a  dis- 
tinct chill,  is  followed  by  dull  pain  and  weight  in  the  right 
hypocondrium,  the  pain  often  radiating  to  the  tip  of  the  right 
shoulder.  The  chilly  sensations  recur.  The  pain  increases  and 
is  aggravated  by  position  and  pressure.  The  tongue  is  brown 
and  furred,  there  is  loss  of  appetite,  slight  nausea,  and  often 
vomiting.  There  is  dyspnoea  and  a  short  dry  cough  resembling 
that  of  pleurisy.  With  the  formation  of  the  abscess,  there  are 
hectic  rigors  and  recurring  night  sweats,  persistent  and  profuse 
vomiting,  the  pain  becomes  sharp  and  localized,  the  temperature 
rises,  and  exhaustion  and  emaciation  are  rapidly  developed. 
Hepatic  abscesses  may  be  discharged  in  a  variety  of  ways  : 
through  the  abdominal  wall,  into  the  peritoneal  cavity,  into  the 
stomach,  intestines,  etc.  (Loomis). 

Physical  Signs. — If  the  abscess  is  large,  inspection  will  show 
a  bulging  of  the  right  hypochondriac  region.  By  palpation  the 
liver  is  enlarged  and  has  an  uneven  feel.  The  pain  is  increased 
by  pressure,  and  localized.  Fluctuation  may  be  present.  By 
percussion  the  area  of  hepatic  dullness  is  increased. 

Prognosis. — The  majority  of  abscesses  of  the  liver  terminate 
fatally. 

Treatment. — When  pus  has  formed,  and  the  locality  of  the 
abscess  can  be  determined,  aspiration  should  be  performed. 
The  abscess  should  be  opened  as  soon  as  possible  (Loomis  ). 

HERPES, 

Is  an  acute,  non-contagious  affection,  characterized  by  the 
development  of  one  or  more  groups  of  vesicles,  and  accompanied 
by  burning  heat,  pain  or  itching,  which  runs  its  course  in  from 
one  to  three  or  four  weeks,  and  may  recur  (  Anderson  ). 


246  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Varieties. — 1.  Herpes  facialis.  2.  Herpes  praeputialis.  3. 
Herpes  iris.     4.  Herpes  zoster,  or  shingles. 

Herpes  facialis  is  the  most  frequent,  and  the  parts  most 
commonly  attacked  are  the  red  portions  of  the  lips,  but  any  part 
of  the  face,  or  even  the  mucous  membrane  of  the  nose,  palate  or 
tongue  may  be  involved.  At  first  there  is  redness  and  burning 
heat,  then  little  elevations  appear,  which  soon  develop  into  vesi- 
cles, often  of  large  size;  these  at  first  are  filled  with  clear  serum, 
which  soon  becomes  opaque  or  even  purulent. 

Causes. — In  many  cases  it  is  consequent  upon  catching  cold, 
or  upon  digestive  derangement.  It  is  also,  a  very  frequent  ac- 
companiment of  febrile  affections,  especially  pneumonia  in  which 
disease  its  occurrence  may  even  aid  the  diagnosis.  Herpes 
preputial  is  is  most  often  met  with  on  the  prepuce,  but  may  be 
seated  upon  the  glans,  or  even  upon  the  skin,  and  in  women 
upon  the  labia.  The  vesicles  very  soon  rupture,  so  that  often  by 
the  time  attention  is  directed  to  the  part  by  the  burning  heat, 
only  a  group  of  little  excoriations  is  to  be  seen.  These  are 
irritated  by  the  secretion  and  may  be  mistaken  for  soft  chancres, 
especially  as  the  eruption  sometimes  follows  connection.  This 
variety  of  herpes  is  often  very  troublesome,  and  may  recur  half 
dozen  times  in  the  course  of  a  year.  It  is  said  to  be  more  apt  to 
occur  in  those  who  have  suffered  from  venereal  diseases.  Herpes 
iris  is  rare,  and  is  met  with  in  young  persons.  It  occurs  in  spring 
and  autumn,  and  attacks  most  usually  the  dorsum  of  the  hands 
and  feet,  and  the  fingers  and  toes.  All  the  colors  of  the  rain- 
bow may  usually  be  observed  at  one  time  or  another  in  the  course 
of  the  disease.  Herpes  zoster  1  or  Shingles,  is  the  most  serious  of 
the  forms  of  herpes,  and  differs  from  the  others  in  that  the  erup- 
tion follows  the  course  of  certain  cutaneous  nerves.  In  its  most 
typical  form,  it  affects  one  side  of  the  chest.  It  may  attack  other 
parts  of  the  trunk  as  well  as  the  extremeties,  the  head  and  neck, 
where  it  also  follows  the  course  of  a  nerve.  Neuralgic  pains 
usually  accompany  it  (Anderson). 

Treatment. — In  all  varieties  of  herpes  the  part  must  be 
dusted  with  some  soothing  powder.  Arsenic  is  the  best  internal 
remedy.     The  diet  should  be  light,  and  saline  aperients  should 


HERPES — -HICCOUGH.  247 

be  used.     Dr.  Meredith    recommends  the   painting    of   the    part 
with  oil  of  peppermint  to  relieve  the  pain  (Anderson.) 

PRESCRIPTIONS  FOR  HERPES. 

|fc     Zinci  oxidi 31J. 

Glycerin* gij. 

Liq.  plumbi  subacetat  dil giss. 

Liq.  calcis §vi.-viij . — M. 

Ft.  lotio. 
Sig. :     Apply  locally.  — Tilbury  Fox. 

J&     Hydrargyri  chloridi  mitis 3J. 

Unguenti  simplicis §j . — M. 

Ft.  ungt. 
Sig. :     Apply  locally.  — Pareira. 

HICCOUGH. 

Treatment, — Apomorphia  cured  a  case  of  persistent  hiccough 
when  hypodermic  injections  of  morphia  and  atropia  had  failed. 
Camphor  has  been  recommended  in  hiccough.  Chloroform,  com- 
bined with  opium,  is  said  to  control  persistent  hiccough  (Ringer). 
A  hypodermic  injection  of  morphia  often  arrests  persistent  hic- 
cough. Cases  of  obstinate  and  even  dangerous  hiccough  are 
reported  which  have  been  immediately  cured  by  drinking  an  in- 
fusion made  with  a  teaspoonful  of  mustard  steeped  in  four 
ounces  of  boiling  water  for  twenty  minutes,  and  then  strained 
(Ringer). 

PRESCRIPTIONS  FOR  HICCOUGH. 

Jfc     Pilocarpine  muriatis gr.  ^. 

A  que  destillatse XHx . — M. 

Sig.:     Inject  hypodermically.  — Ortille. 

Jfc     Pulveris  sinapis 5j- 

Aqua?  bullientis , 3 iv. — M. 

Ft.  infusum. 
Sig. :     Take  at  one  draught.  — Ringer. 

Jfc     Apomorphia?  muriatis gr.  -fa. 

Aqiue  destillata.'  2.1Tx. — M. 

Sig.:     Inject  hypodermically.  — Ringer. 


248  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

HYDROCEPHALUS. 

Is  dropsy  of  the  brain.  It  may  be  congenital  or  acquired. 
The  congenital  consists  in  an  excess  of  the  cerebro- spinal  fluid, 
lying  either  externally  to  the  brain,  or  more  frequently  in  its  in- 
terior (Smith). 

Causes. — Syphilis  may  be  a  cause  of  congenital  hydrocepha- 
lus, but  in  many  cases  the  cause  is  unknown.  It  may  be  associ- 
ated with  spina  bifida  (Smith,  J.  L.) 

Symptoms. — -While  the  volume  of  the  head  increases,  emaci- 
ation of  the  neck,  trunk  and  limbs  is  common.  In  the  last 
stages,  there  is  more  or  less  vomiting.  As  the  liquid  increases, 
the  child  becomes  drowsy  and  takes  no  notice  of  objects,  and 
finally  convulsions  occur  (J.  L.  Smith). 

Prognosis. — Unfavorable, 

Treatment. — Digitalis,  squills,  acetate  of  potassium,  and 
iodide  of  potassium  are  the  remedies  for  this  affection.  One  or 
two  grains  of  iodide  of  potassium  may  be  given  every  two  hours 
to  an  infant  of  three  months.  A  close-fitting  cap  may  partially 
prevent  the  expansion  of  the  head.  Tapping  frequently  gives 
temporary  relief,  and  should  be  performed  with  a  very  small 
trocar,  which  should  be  introduced  in  the  coronal  suture  about 
an  inch  external  to  the  anterior  fontanel  (J.  L.  Smith). 

Causes  of  Acquired  Hydrocephalus. — Meningeal  inflammations, 
tumors  or  other  causes  which  obstruct  the  venous  circulation, 
prolonged  passive  congestion,  affections  of  an  exhausting  nature, 
and  protracted  infantile  diarrhoea. 

Symptoms. — The  child  has  headache,  is  irritable,  is  delirious, 
drowsy,  and  its  head  seems  too  heavy  for  its  body  and  is  buried 
in  the  pillow  (J.  L.  Smith). 

Prognosis. — Unfavorable. 

Treatment  for  the  Acquired. — Cold  applications  to  the  head. 
The  bowels  should  be  kept  open,  and  derivatives  should  be 
applied  to  the  feet  and  back  of  the  neck.  The  acetate  and  iodide 
of  potassium  may  be  given,  and  vesication  should  be  produced 
behind  the  ears  (J.  L.  Smith). 


HYDROCEPHALUS HYDEOTHOEAX.  249 

PRESCRIPTIONS  FOR  HYDROCEPHALUS. 

J2r     Collodii  cum    cantharides ^iv. 

Sig. :     Paint  the  back  of  neck  every  few  days.  — Hartshorne. 

#     Olei  tiglii  rrtij. 

Mucil  acacise 3ij. 

Aquae  destillatse §j. — M. 

Sig.:     The  fourth  part  every  four  hours.     (Said    to  remove  fluid 
from  the  ventricles).  — Dungleson. 

|&     Potassii  iodidi 3ss-j. 

Syrupi  aurantii  cort SJ. 

Aqua? ad 5  iv. — M. 

Sig.:     A  teaspoonful  every  two  hours  to  an  infant  of  six  months. 

—J.  L.  Smith. 

HYDROTHORAX. 

A  dropsy  having  its  seat  in  the  pleural  cavity  is  called  hy- 
drothorax,  or  water  on  the  chest.  It  differs  from  pleurisy  in  the 
character  of  the  fluid  and  in  the  state  of  the  pleura.  In  pleurisy 
the  effusion  is  an  inflammatory  exudation,  and  the  pleura  is  the 
seat  of  an  inflammation;  in  hydrothorax  the  fluid  transudes,  and 
the  pleura  is  unaffected  (Bartholow). 

Causes. — It  is  due  to  an  organic  disease  of  the  liver,  heart, 
or  kidneys,  and  the  serum  collects  in  both  pleural  sacs.  An  ef- 
fusion caused  by  an  inflammation  of  the  pleura  is  nearly  always 
one  sided.  It  may  occur  in  any  exhausting  disease  which  causes 
general  hydraeinia,  and  is  usually  associated  with  dropsies  in  other 
parts  of  the  body.  Chronic  malarial  poisoning  and  Bright's  dis- 
ease may  cause  it. 

Symptoms. — There  is  no  fever  nor  pain  in  the  side.  The 
first  symptom  referable  to  the  thorax  is  increasing  difficulty  of 
breathing,  until  the  patient  reaches  a  condition  of  extreme  dis- 
tress; the  lips  become  livid,  the  finger  ends  blue,  and  the  respira- 
tion gasping.  He  is  unable  to  lie  down,  and  can  speak  with  dif- 
ficulty. There  may  be  a  short  dry  cough-  The  physical  signs 
of  hydrothorax  is  fluid  in  both  pleural  cavities,  which  is  not  at- 
tended by  friction  sounds  or  vocal  fremitus  (Loomis). 

Treatment.- — If  there  is  much  effusion,  delay  is  unsafe  and 
thoracentesis   should  be  promptly  performed.     As   scrum  will 


250  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

flow  through  a  fine  capillary  needle,  but  little  pain  and  no  dan- 
ger attend  the  operation  of  aspiration.  Such  remedies  as  hydra  - 
gogue  cathartics,  and  diuretics  are  useful.  Elaterium  is  the  best. 
Digitalis  should  be  given  (Bartholow  and  Loomis). 

HYPOCHONDRIASIS. 

Is  a  disorder  of  the  mind,  but  the  mental  aberration  is  not 
regarded  as  amounting  to  insanity,  and  patients  with  this  affec- 
tion are  not  proper  subjects  for  treatment  at  lunatic  asylums. 
Cases  are  frequent  and  they  claim  the  services  of  the  general 
practitioner. 

The  characteristic  feature  of  the  affection  is  a  morbid 
apprehension  of  either  the  existence  of,  or  a  liability  to  some 
serious  disease  (Flint). 

Forms. — In  its  mildest  form  it  consists  of  a  feeling  of  ex- 
treme delicacy  of  constitution.  Existing  in  this  form,  it  leads  to 
an  anxiety  concerning  health  and  over-precautions  for  its  preser- 
vation. In  the  severest  form  of  the  affection,  patients  suffer 
from  the  conviction  that  they  have  an  incurable  malady.  The 
hypochondriac  is  the  victim  of  a  delusion  with  respect  to  his 
condition.  Disease  of  the  heart,  consumption,  cancer,  syphilis, 
tapeworm,  softening  of  the  brain  and  diabetes  are  among  the 
diseases  which  in  different  cases  are  supposed  to  exist.  Hypo- 
chondriacs frequently  consult  many  physicians  in  succession,  but 
no  one  is  able  to  convince  him  of  his  delusion.  Persons  of  edu- 
cation and  strong  mental  powers  are  as  liable  to  the  affection  as 
those  who  are  ignorant  and  of  feeble  mind.  Some  patients 
imagine  they  have  one  particular  disease,  others  imagine  they 
have  various  diseases,  or  fix  upon  one  for  a  time  and  then  another 
(Flint). 

Causes. — Are  both  physical  and  mental.  Some  persons  are 
constitutionally  liable  to  morbid  apprehensions  in  this  direction. 
Whenever  they  are  ill  with  any  affection,  their  mental  constitu- 
tion leads  to  a  sense  of  danger,  and  to  despondency  as  regards 
recovery.  This  state  of  mind  exerts  a  depressing  influence  which 
may  interfere  seriously  with  the  favorable  progress  of  disease. 
Masturbation,  excessive  sexual  indulgence  and  the  intemperate 
use  of  alcoholic  stimulants  are  causative. 


HYPOCHONDRIASIS.  251 

The  reading  of  legitimate  medical  works  is  to  be  mentioned 
among  the  causes  of  hypochondriasis.  Want  of  mental  occuj3a- 
tion  may  cause  it;  and  persons  who  have  relinquished  active  pur- 
suits often  become  hypochondriacs.     Misfortunes  are  causative. 

The  physical  disorders  are  anaemia,  neurasthenia  and  dys- 
pepsia. 

Treatment. — Remove  the  supposed  causes  if  possible.  Over- 
exertion, mental  or  physical,  is  to  be  avoided.  Sexual  abuses, 
intemperance  and  any  violation  of  the  laws  of  health  are  to  be 
inquired  into  and  reformed.  Anaemia  and  dyspeptic  ailments 
claim  treatment.  Remedies  have  a  useful  moral  effect  within 
certain  limits.  Patients  often  crave  remedies.  The  mental 
treatment  is  the  most  important.  It  is  not  wise  to  attempt  to 
dispel  the  delusions  by  ridicule  or  indifference,  but  by  argument 
and  assurances.  The  patient's  attention  should  be  diverted  from 
himself.  Change  of  scene  and  new  associations  should  be  ad- 
vised. 

PRESCRIPTIONS  FOR  HYPOCHONDRIASIS. 

R     Liq.  potassii  arsenitis XTTxL. 

Tinct.  opii oi • 

Aquae  menthse  pip.. ad  giiss. — M. 

Sig. :     A  teaspoonful  three  times    daily.     (In  aged  with  gloomy 
fancies).  — Lemare-Picquot. 

R     Morphia?  sulphatis gr.  i-ij. 

Sacchari  lactis gr.  x. — M. 

In  pulv.  no.  xii.  div    

Sig. :     A  powder  three  times  daily  for  at  least  two  months. 

— Hammond. 

R     Mist  asafoetidas §iv. 

Sig.:     One  to  two  teaspoonfuls  three  or  four  times  daily. 

—  Bartlmlow. 

R     Potassii  bromidi §ss. 

In  pulv.  no.  xii.  div. 
Sig.:     A  powder  in  cold  water  three  times  daily.  — Ringer. 

R     Auri  chloridi gr.  i-iss. 

Ext.  gentianae gr.  xv. — M. 

Ft.  massa  et  in  pil.  no.  xxx.  div. 
Sig.:     One  pill  thrice  daily.  — Bartholow. 


252  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

HYSTERIA. 

Is  a  functional  nervous  trouble,  characterized  by  various 
motor,  sensory  and  intellectual  disturbances  (Bartholow). 

Causes. — Hysteria  is  almost  exclusively  confined  to  women. 
It  is  most  frequent  between  the  ages  of  fifteen  and  twenty- five. 
If  the  neurotic  type  of  constitution  is  inherited,  in  one  genera- 
tion it  may  assume  the  shape  of  hysteria;  in  the  next  epilepsy; 
and  in  the  third  insanity.  It  is  not  due  to  derangement  of  the 
uterus  and  ovaries,  but  to  a  peculiar  morbid  state  of  the  nervous 
system.  This  peculiar  state  of  the  nervous  system  may  be 
acquired  by  faults  of  early  training,  by  a  lack  of  personal  discip- 
line; by  mortification  or  chagrin.  Anaemia  and  an  impoverished 
condition  of  the  blood  may  cause  hysteria.  The  disturbances 
may  be  in  the  digestive  system,  in  the  circulatory,  in  the  sexual, 
or  in  the  nervous.  It  is  most  liable  to  occur  in  members  of 
families  in  which  epilepsy,  chorea,  catalepsy  and  insanity  have 
occurred.  Fright,  anger,  jealousy,  grief  and  disappointment 
predispose  to  its  development.  Among  savage  nations  and  hard 
working  women  it  is  unknown  or  rare.  It  is  apparently  con- 
tagious (Bartholow  and  Loomis). 

Symptoms. — The  first  symptoms  are  usually  trivial — mere 
irritability  of  disposition,  rapid  changes  of  feeling,  noisy  transi- 
tions of  sadness  and  joy,  tears  and  laughter.  There  are  quick 
alternations  of  cold  and  heat,  that  are  purely  subjective;  numb- 
ness, tingling,  suffocative  feelings,  pain  around  the  heart,  palpi- 
tations, quick  breathing,  a  sense  of  fullness  of  the  stomach,  eruc- 
tations of  gas,  and  the  rising  of  a  globe  to  the  larynx  (globus 
hystericus),  producing  a  sensation  of  choking,  restlessness,  the 
whole  ending,  it  may  be,  in  prolonged  laughter,  but  more  usually 
in  crying,  and  in  a  profuse  urinary  discharge,  the  urine  being 
jjale  and  watery.  In  the  more  severe  attacks,  patients  laugh  and 
cry,  choke,  gasp  for  breath,  sob  and  cough;  the  jaws  are  fixed, 
the  face  retracted,  the  teeth  grinding  together,  the  hands  clinched, 
the  limbs  drawn  up  and  rigid.  In  some  cases  there  are  tonic  and 
clonic  convulsions.  There  is  no  loss  of  consciousness.  In  some 
cases  there  is  a  death-like  pallor  of  the  face  and  half- closed 
eyes.     The  attack  is  more  apt  to   occur   during  the  menstrual 


HYSTERIA.  253 

period.  Headache  is  the  most  common  form  of  pain.  Colics  are 
frequent.  Paralysis  is  sometimes  a  symptom  of  hysteria.  Gas- 
tralgia,  irritable  bladder  and  spinal  irritation  are  frequent  symp- 
toms (Bartholow).  During  their  hysterical  paroxysms,  they 
always  want  an  audience;  they  crave  attention  and  sympathy. 
Pain  in  the  skull,  as  if  a  nail  were  being  driven  into  the  head,  <  >r 
a  kettle  were  simmering  on  top  of  it,  called  by  the  ancient  phv- 
sicians  clavus  hystericus,  is  by  many  regared  as  jDathognonionic. 
The  whole  or  only  a  part  of  the  cutaneous  surface  may  be 
hypersesthetic  or  anaesthetic.     There  is  often  pain  in  the  joints. 

Differential  Diagnosis. — Hysteria  may  be  mistaken  for  epil- 
epsy, hypochondria  and  neuralgia.  It  is  distinguished  from 
epilepsy  by  its  slow  onset,  by  incomplete  coma,  a  normal  pupil, 
sobbing  and  crying.  The  tongue  is  not  bitten  in  hysteria.  In 
hypochondria  the  patient  is  alvrays  morose;  there  are  not  those 
variations  in  temper  that  are  so  characteristic  of  hysteria. 
Hypochondria  is  rare  before  the  thirtieth  year,  is  more  common 
in  men  than  in  women.  The  two  diseases  may  be  conjoined 
(Loomis).  Neuralgia,  if  of  hysterical  origin,  ceases  when  the 
patient1*  attention  is  diverted. 

Treatment. — Moral  and  hygienic  measures  are  most  impor- 
tant. Self-control  should  be  instilled  into  the  mind.  Early 
hours,  substantial  food,  and  plain  clothing  should  be  insisted 
upon,  while  society,  the  follies  of  dress  and  fashion,  and  dainties 
should  be  prohibited.  The  proper  books  should  be  selected  for 
young  ladies.  Sexual  abuses  have  an  injurious  effect  on  the  ner- 
vous system.  For  anaemia,  iron,  arsenic,  and  strychnine  should 
be  given.  For  the  seizure,  a  little  fluid  extract  of  valerian,  or  a 
few  drops  of  Hoffman's  anodyne  repeated  every  few  minutes  will 
terminate  the  attack.  In  the  convulsive  form,  inhalations  of 
amyl  nitrite  or  of  ethyl  bromide  may  be  practiced.  The  mi- 
graine may  be  cured  by  use  of  mix  vomica,  arsenic,  aconitine, 
and  galvanism.  Hysterical  aphonia  and  dysphagia  may  some- 
times be  cured  instantly  by  faradic  applications-  Anaesthesia  is 
best  treated  by  the  electric  brush.  The  various  forms  of  hyster- 
ical paralysis  require  faradic  applications.  Mitchell  has  devised 
a  plan  of  treatment  for  bed  fast  hysterical  subjects  which  seems 
very  successful.     It    consists  in  the  combined  use  of  massa  ge, 


254  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

faradization,  and  forced  feeding.  Massage  consists  in  friction, 
kneading  and  tapping  of  all  the  muscles,  in  passive  motion  to  all 
the  joints.  The  diet  consists  at  first  of  milk  only.  Xo  exercise 
is  allowed,  but  all  movements  are  made  for  the  patient.  The 
patient  is  separated  from  all  her  former  associations  and  the  su- 
perabundant sympathy  of  home.  She  is  placed  in  bed  in  charge 
of  a  nurse,  and  not  permitted  to  move;  the  desire  for  action 
grows  out  of  the  utterly  monotonous  idleness  (Bartholow). 

PRESCRIPTIONS  FOR  HYSTERIA. 

R     Tinct.  opii  oj- 

Tinct.  nucis  vomicae 31J. — M. 

Sig. :     Three  drops  in  water  thrice  daily.     (For   weight  on  the 
head,  flushings,  hot  and  cold  perspiration).  — Ringer. 

R     Paraldehyde  rtlxxx. 

Syrupi  simplicis 3ss. 

Aqua?  roenthae  pip 5J. — M. 

Ft.  haustus. 
Sig.:     To  be  taken  at  a  draught.     (To  produce  sleep). 

R      Spiritus  aetheis  compositi  

Tinct.  valerians  amnion aa...§j. — M. 

Sig. :     A  teaspoonful  in  water  every  fifteen  minutes  until  relieved. 

— Bartholow. 

R     Apomorphiae  muriatis gr.  j . 

Syrupi  simplicis 3iv. 

Aquae ad 3x. — M. 

Sig.     A    teaspoonful    as  required.     Repeat   in   a    few   hours  if 
necessary.  — Ringer. 

R     Ext.  salicis  nigri 

Elixir  simplicis aa 3  j. — M. 

Sig.:     A  teaspoonful  three  times  daily.  — Hutchinson. 

R      Ferri  citratis  oij- 

Syr.  simplicis  5ss. 

Aquae  aurantii  flor ad Svi. — M. 

Sig.:     A  tablespoonful  three  times,  daily.  — Hartshorne. 

R     Ammonii   bromidi oij- 

Spiritus  ammoniae   aromat 5i- 

Aquae §iv. — M. 

Sig.:     A  dessertspoonful  thrice  daily.  — Hartshorne. 


HYSTEEIA HEAT    STROKE.  255 

J&     Liquoris  potassii  arsenitis gss. 

Sig. :     Three  to  five  drops  thrice  daily  after  meals.    — Bartholow. 

Jfc     Extracti  conii  fluidi. 

Ext.  hyoscyami  fild aa IHvij. 

Chloral  hydratis gr.  x. 

Aqua? ad §j. — M. 

Ft.  haustus. 
Sig.:     To  be  taken  as  a  single  dose  and  repeated  as  required. 

— Madigan. 

HEAT  STROKE. 

Called  also  sunstroke,  insolation,  or  heat  fever,  is  the  com- 
plex of  symptoms  occurring  in  jjersons  exposed  to  extreme  heat 
nnder  unfavorable  circumstances  (Loomis). 

Causes. — It  is  due  to  the  influence  of  excessive  heat — natural 
or  artificial.  The  habitual  consumption  of  spirits,  beer,  and  al- 
coholic beverages,  and  excessive  fatigue  and  overcrowding  pre- 
dispose to  attacks.  Workmen,  soldiers  on  the  march,  cab-driv- 
ers, or  brain  workers  are  more  liable  to  be  overcome  by  the  heat. 
Hot,  wet,  muggy  days — our  August  clog- days — are  the  most  fa- 
vorable for  its  occurrence.  In  Dakota  men  can  work  all  day  ex- 
posed to  the  sun  when  the  temperature  of  the  air  is  at  least  140° 
to  160°  while  in  New  York  on  a  cloudy,  wet  day  in  August, 
with  the  temperature  at  only  93  degrees,  large  numbers  of  men 
and  animals  are  prostrated  (Loomis). 

Symptoms. — The  majority  of  the  cases  occur  in  the  middle  of 
the  day.  In  mild  cases  the  patient  suddenly  becomes  exhausted, 
and  probably  faints,  or  becomes  semi- comatose.  He  is  utterly 
jDrostrated;  the  skin  is  pale,  cold  and  moist;  the  pulse  is  quick 
and  feeble,  and  all  kinds  of  symptoms  are  referred  to  the  head — ■ 
floating,  swimming,  vertigo,  fullness  and  neuralgic  pain.  These 
cases  may  recover  or  terminate  fatally  from  heart  failure.  In  a 
severer  form,  a  man  may  be  struck  down  suddenly,  unconscious- 
ness suddenly  follows;  the  skin  is  cold,  the  jduIsc  is  feeble,  and 
death  may  result  from  heart  failure.  In  another  form  called 
thermic  fever,  the  temperature  rises  to  108°  or  110°  F.  or 
even  higher.  This  is  due  to  the  influence  of  heat  on  the  nerve 
centre.     It  often  occurs  at  night  and  in  those  who  are  dissipated 


256  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

or  worn  out.  There  is  great  restlessness,  thirst,  dysjDncea,  and 
the  shin  is  burning  hot.  Delirium  and  epileptiform  convulsions 
are  common,  and  finally  the  patient  passes  into  a  complete  coma, 
with  sterterous  breathing  (Loomis). 

Differential  Diagnosis. — It  may  be  mistaken  for  acute  menin- 
gitis. In  the  latter  the  projectile  vomiting,  the  boat  belly,  the 
pale  face,  and  the  tense,  hard,  wiry  pulse  are  in  striking  contrast 
to  the  symptoms  of  sun- stroke.  Acute  alcoholismus  may  be  con- 
founded with  sun- stroke,  but  the  history  of  the  case  will  decide 
(Loomis). 

Prognosis. — Except  in  mild  cases,  is  very  bad;  nearly  one- 
half  die  (Loomis). 

Treatment. — The  patient  must  have  absolute  rest  and  plenty 
of  cool,  fresh  air.  Stimulants  are  often  necessary.  In  most 
cases  the  cold  water  treatment  is  the  best.  The  patient  should 
be  taken  to  the  nearest  pump,  stream  or  water-tank  and  im- 
mersed for  a  considerable  time,  or  a  stream  of  cold  water  should 
be  poured  over  the  head,  neck  and  back.  In  the  thermic  fever 
form,  ice  water  should  be  applied  to  the  surface,  the  bowels 
should  be  moved  by  a  saline  and  morphine  and  quinine  given. 
The  inhalation  of  ether  or  chloroform  is  often  of  service  in  this 
form  (Loomis). 

HECTIC  FEVER. 

Is  a  fever  of  irritation.  It  accompanies  many  chronic  dis- 
eases in  which  destruction  of  tissues  occur,  especially  phthisis. 
It  is  a  form  of  remittent  fever,  consisting  of  an  exacerbation, 
once  or  sometimes  twice  a  day,  depending  on  suppuration  in 
many  cases  (DaCosta). 

Symptoms. — One  of  the  first  symptoms  is  a  slight  increasing 
frequency  of  pulse,  and  a  small  degree  of  heat  of  skin,  generally 
toward  evening.  The  heat  is  especially  felt  in  the  palms  of  the 
hands  and  the  soles  of  the  feet.  The  fever  reaches  its  height 
about  midnight  and  terminates  by  a  profuse  perspiration  toward 
morning.  The  respiration  is  quick  ancl  short.  The  appearance 
of  the  face  is  characteristic,  there  being  a  circumscribed  blush  in 
the  centre,  known  as  the  "hectic  flush."  The  patient  loses  flesh 
rapidly.     The  pulse  is  above  80  and  is  soft.     The  temperature 


HECTIC    FEVER HIVES HOARSENESS.  257 

as  a  rule  varies  from  99°  to  101°  F.  Hectic  fever  is  always 
symptomatic  of  some  particular  disease,  of  profuse  discharge,  as 
of  pus  or  blood,  or  of  an  abscess  of  the  brain,  lungs  or  liver,  and 
is  in  part  due  to  the  entrance  of  septic  products  into  the  blood, 
as  in  septicaemia. 

Treatment. — Remove  the  diseased  part,  or  let  out  the  pus. 
The  diet  should  consist  of  animal  and  farinaceous  food,  eo-gs, 
macaroni,  milk,  wine,  beer,  etc.  Quinine,  sulphuric  acid  and 
iron  are  the  medicines  generally  indicated.  For  diarrhoea,  aro- 
matic sulphuric  acid,  opium,  and  chalk  mixture  are  efficient. 

Night  Sweats. — Sponge  the  surface  with  cold  water,  or 
alum  and  water.  Fifteen  drops  of  aromatic  sulphuric  acid 
three  times  daily,  or  an  sV  gr.  of  sulphate  of  atropia  combined 
or  not  with  oxide  of  zinc,  two  or  three  grains,  may  be  given  at 
bedtime  (Compend). 

PRESCRIPTIONS  FOR  HECTIC  FEVER. 

R     Quinine  sulphatis oj- 

In  pulv.  no.  xii.  div 

Sig.:     A  powder  in  water  three  times  daily.  — Phillips. 

R     Syr.  calcis  lactophosphat Siv. 

Sig. :     A  teaspoonful  three  times  daily.  — Beneke. 

R     Tinct.  digitalis giij. 

Tinct.  ferri  chloridi  gv. — M. 

Sig. :     Fifteen  drops  in  water  three  times  daily.         — Bartholow. 

R     Antipyrin  gr.  xL. 

Aqute  oviij. — M. 

Sig. :     Two  tablespoonfuls,  followed   by  one   tablespoonral  every 
hour  till  temperature  is  normal.  — Pribram. 

HIVES.     (See  Urticaria). 

HOARSENESS. 

Treatment. — Chronic  bronchitis  and  hoarseness  produced  by 
singing  and  by  simple  acute  catarrh  are  relieved  by  ten  minim 
doses  of  dilute  nitric  acid.  Aphonia  due  to  fatigue  of  the  vocal 
cords  and  hysterical  aphonia  may  be  removed  very  speedily  by  a 


258  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

morning  and  evening  dose,  (yio-sV  of  a  grain)  of  atropine  (Bar- 
tholow). 

Ten  grains  of  alum  to  the  ounce  of  water  is  used  in  the 
form  of  spray  for  chronic  coughs  and  hoarseness  (Ringer). 

Dr.  Carson  finds  that  a  piece  of  borax  the  size  of  a  pea,  dis- 
solved in  the  mouth,  acts  magically  in  restoring  the  voice  in 
cases  of  sudden  hoarseness  brought  on  by  a  cold,  and  frequently 
for  an  hour  or  so,  it  renders  the  voice  "silvery  and  clear." 
Borax  is  useful  in  hoarseness  common  among  clergymen  and 
■singers.  In  chronic  inflammation  of  the  throat,  a  few  applica- 
tions of  glycerine  of  tannin  brace  up  the  tissues  and  lessen  or 
remove  the  hoarseness.  The  ipecac  (wine)  spray  is  useful  in 
hoarseness  from  congestion  of  the  vocal  cords.  Where  the 
hoarseness  has  lasted  a  few  days  only,  or  one  or  two  weeks,  the 
spray  often  speedily  cures.  At  the  commencement  of  a  feverish 
cold,  a  Turkish  bath  will  cut  the  attack  short,  remove  the  aching 
pains,  and  relieve  or  cure  the  hoarseness  at  once  (Ringer). 

HORDEOLUM.  (See  Stye.) 
HOUSEMAID'S  KNEE. 

Is  an  inflammation  of  the  bursa  of  the  knee,  between  the 
patella  and  skin,  which  is  common  to  housemaids,  from  kneeling. 
It  is  usually  chronic,  but  may  be  acute.  It  causes  great  pain  and 
swelling,  the  swelling  being  superficial  and  in  front  of  the 
patella.  An  enlargement  of  the  bursa  at  the  elbow  is  called 
"miner's  elbow."  Bryant  has  seen  the  bursa  enlarge  over  the 
acromian  process  in  men  who  carry  timber;  over  the  tuberosity 
of  the  ischium  in  weavers;  over  the  external  malleolus  in  tailors; 
over  the  malleoli,  and  also  the  instep,  from  pressure  of  a  boot; 
over  the  ball  of  the  great  toe  in  cases  of  bunion,  etc. 

Treatment. — Rest,  leeches,  fomentations  and  purgatives;  if 
these  do  not  bring  relief,  an  incision  should  be  made  into  the 
swelling.  After  evacuating  the  contents  of  the  sac,  a  small 
quantity  of  equal  parts  of  tincture  of  iodine  and  alcohol  should 
be  injected  into  it.  Dr.  Lewis  recommends  injections  of  carbolic 
acid.     It  may  be  tapped  (Bryant  and  others). 


HYDROCELE HEMATOCELE.  259 

HYDROCELE. 

Is  an  accumulation  of  serum  in  the  tunica  vaginalis  testis, 
and  it  may  be  of  the  spermatic  cord.  The  swelling  of  hydrocele 
first  shows  itself  at  the  lower  part  of  the  scrotum  and  gradually 
rises  till  it  arrives  at  the  abdominal  ring.  It  is  of  a  pyriform 
shape.  Usually  it  is  attended  with  pain.  Commonly  there  is  no 
discoloration  of  the  scrotum.  In  hydrocele  the  testicle  is  two- 
thirds  of  the  way  down  the  tumor  at  the  posterior  part,  but  it 
may  sometimes  be  found  in  front,  or  at  the  bottom.  The  diag- 
nostic signs  are  a  sense  of  fluctuation,  transparency,  lightness  and 
freedom  from  j^ain.  In  very  old  cases  the  transparency  may  be 
absent. 

Congenital  Hydrocele. — When  the  tunica  vaginalis  j)reserves 
its  communication  with  the  abdomen,  and  then  becomes  filled 
with  serum,  it  is  called  congenital  hydrocele.  On  being  raised 
and  compressed  the  fluid  is  slowly  squeezed  into  the  abdomen, 
and  slowly  trickles  down  again  afterward. 

Treatment. — Is  either  palliative  or  curative.  The  evacua- 
tion of  the  serum  constitutes  the  palliative  treatment.  This  is 
accomplished  by  a  puncture  with  a  small  trocar  and  canula. 
Palliative  treatment  is  sufficient  for  children,  but  rarely  so  in  the 
case  of  adults.  The  radical  cure  is  performed  by  injecting  into 
the  sac  a  fluid  composed  of  one  drachm  of  tincture  of  iodine,  and 
one  or  two  drachms  of  water,  after  first  having  withdrawn  all 
the  serum  from  the  sac.  When  the  inflammation  subsides  the 
fluid  generally  secretes  no  longer.  Dr.  Lewis  recommends  injec- 
tions of  a  half  a  drachm  to  a  drachm  of  pure  carbolic  acid  lique- 
fied with  water  or  glycerine  into  the  sac.  In  obstinate  cases,  a 
free  incision  into  the  tunica  vaginalis,  and  the  filling  of  the 
cavity  with  carbolic  or  iodoform  gauze  to  make  it  fill  up  by 
granulation,  is  also  to  be  recommended  (Bryant). 

HEMATOCELE. 

Is  an  extravasation  of  blood  into  the  tunica  vaginalis.  It 
may  occur  as  the  result  of  a  blow,  strain,  or  the  tapping  of  a 
hydrocele,  or  it  may  arise  without  any  assignable  cause. 


260  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

There  is  swelling  of  the  part,  which  comes  on  immediately, 
or  soon  after  the  receipt  of  the  injury.  It  resembles  hydrocele 
as  regards  shape.  At  first  the  tumor  is  soft,  and  fluctuation  may 
he  detected,  but  when  the  blood  coagulates  it  resembles  in  its 
character  a  solid  growth.  There  is  testicular  j)ain  on  pressure. 
It  is  a  non- transparent  tumor,  smooth  and  tense  (Bryant). 

Treatment. — In  a  recent  case  the  first  indications  are  to 
arrest  the  flow  of  blood  and  relieve  pain.  The  recumbent  posi- 
tion, with  testicles  raised,  is  necessary;  the  ice-bag  and  cold 
lotions  must  be  apjDiied.  If  the  blood  remains  fluid  for  a  long 
time,  tapping  may  be  performed.  In  chronic  cases  where  there 
are  signs  of  suppuration,  a  free  incision  should  be  made  into  the 
vaginal  sac,  and  the  cysts  and  clots  turned  out.  Then  will 
follow  the  usual  treatment  to  promote  healing  by  granulation 
(Bryant). 

HYPERIDROSIS,     (See  Ephidrosis.) 
H^MIDROSIS. 

Is  an  affection  characterized  by  a  flow  of  blood  from  the  skin 
independent  of  any  pre-existing  lesion  as  a  wound,  abrasion  or 
ulcer.  The  term  literally  signifies  bloody  sweat.  Discharges  of 
blood  from  wounds,  abrasions  and  ulcers  of  the  skin  in  connec- 
tion with  menstruation,  are  quite  common;  but  cases  in  which 
the  flow  takes  place  without  any  lesions  are  exceedingly  rare. 

Causes. — The  disease  occurs  most  frequently  in  females,  and 
in  connection  with  amenorrhcea  or  defective  menstruation,  being 
in  fact,  a  species  of  vicarious  menstruation.  It  has  been  known 
to  occur  in  infants  and  in  adult  males.  It  has  been  supposed 
that  the  hemorrhage  is  due  to  debility  and  deterioration  of  the 
blood. 

Treatment. — When  the  disease  occurs  in  females  in  connec- 
tion with  the  anomalies  of  menstruation,  these  must  be  corrected 
by  the  usual  means.  The  abstraction  of  blood,  local  and  gen- 
eral, is  likely  to  prove  serviceable  and  to  stop  the  discharge.  If 
the  hemorrhage  seems  to  be  due  to  debilit}^,  a  nourishing  diet,, 
stimulants  and  tonics  are  indicated  (Anderson). 


HODGKIx's    DISEASE — HYMEN HYPOSPADIAS.  261 

HODGKIN'S  DISEASE.     (See  Lymphadenoma). 
HYMEN.     (Imperforate  and  Rigid). 

Imperforate  hymen  is  a  condition  to  be  recognized  and  not 
confused  with  adherent  labia.  The  hymen  is  more  deeply 
placed  and  nearer  the  orifice  of  the  vagina.  When  imperforate,  it 
causes  retention  of  the  menses,  the  accumulation  of  the  secre- 
tions, and  a  j3elvic  tumor  usually  accompanied  by  periodic  pain 
and  constitutional  disturbance  (Bryant). 

Treatment. — Division  of  the  imperforate  membrane,  or  its 
complete  excision  to  allow  of  the  free  escape  of  the  secretions 
which  are  usually  black,  is  the  proper  treatment  (Bryant).  A 
rigid  hymen  is  occasionally  an  impediment  to  coitus  in  women 
who  marry  late  in  life;  and  Thomas  Bryant  has  been  called  upon 
on  one  occasion  to  divide  the  hymen  of  a  lady  about  thirty  who 
had  been  married  for  some  months  and  had  never  had  complete 
connection. 

HYPOSPADIAS. 

Is  a  malformation  in  which  the  canal  of  the  urethra,  instead 
of  opening  at  the  apex  of  the  glans,  terminates  at  the  base  or 
beneath  the  penis.  It  is  a  congenital  deformity  and  is  due  to  an 
arrest  of  development  of  a  portion  of  the  lower  wall  of  the 
urethra.  Hypospadias  is  much  more  common  than  epispadias. 
In  examining  sixty  thousand  conscripts,  Marchal  did  not  find  a 
a  single  case  of  epispadias;  but  among  three  thousand  conscripts 
ten  cases  of  hypospadias  were  found.  Hypospadias  may  occur  at 
any  point  in  front  of  the  membranous  urethra,  but  is  more  fre- 
quently confined  to  the  glans  penis.  The  only  disturbances 
caused  by  hypospadias  are  functional.  The  patient  may  not  be 
able  to  pass  water  without  wetting  himself,  and  if  the  opening  is 
too  low  in  the  canal  he  may  be  impotent  (Keyes  ). 

Treatment. — Simple  hypospadias  rarely  calls  for  surgical  in- 
terference, and  hypospadias  of  the  glans  penis  is  unimportant. 
The  operations  which  have  been  performed  for  its  relief  are  not 
very  encouraging  in  their  results  (Keyes  ). 


262  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

HEAD  INJURIES. 

Must  not  be  neglected,  however  trivial.  They  may  be  fol- 
lowed by  erysipelas,  inflammation  and  suppuration. 

Treatment, — They  should  be  sutured  at  once  with  edges 
carefully  coapted.  Care  should  be  taken  to  wash  away  all  for- 
eign bodies  and  clots  with  bichloride  of  mercury  solution  and  a 
syringe.  No  part  of  the  scalp  however  torn  should  be  cut  away. 
The  patient  should  be  confined  to  bed,  or  to  the  house,  purged 
and  put  on  a  milk  diet.  The  hemorrhage  from  small  vessels  is 
usually  controlled  by  closing  the  wound  and  using  pressure; 
larger  vessels  must  be  tied  (Bryant). 

Caution. — Every  scalp  wound  should  be  carefully  examined 
with  the  finger  and  probe,  to  ascertain  whether  or  not  fracture 
of  the  skull  exists.  If  suppuration  occurs  as  indicated  by  rigors, 
chills,  dry  tongue,  with  increase  of  swelling  and  throbbing  pain, 
the  adhesions  must  be  separated  and  pus  let  out  (Bryant). 

HORNS. 

While  horns  occur  normally  on  the  heads  of  many  of  the 
lower  animals,  they  are  rarely  met  with  in  man. 

Causes. — We  know  very  little  with  regard  to  the  causes 
which  induce  them.  It  is  probable  that  in  many  cases  at  least 
local  irritation  has  something  to  do  with  their  production. 

Situation. — They  are  most  commonly  met  with  on  the  head 
and  face,  although  any  part  may  be  implicated.  They  are  more 
common  in  females,  and  are  usually  seen  in  persons  who  have 
passed  middle  life.  Usually  they  are  solitary,  but  occasionally 
multiple.  Botge  has  reported  the  case  of  a  girl  aged  19  who 
had  a  horn  close  to  the  navel  about  six  inches  in  length,  while 
on  the  right  labium  there  was  one  but  a  trifle  shorter.  The  most 
remarkable  case  is  that  of  a  Mexican  porter  who  had  a  horn  on 
the  upper  and  lateral  part  of  his  head  which  was  fourteen  inches 
in  circumference  around  its  shaft  and  divided  above  that  point 
into  three  branches.  Horns  spring  from  the  mucous  layer  of  the 
epidermis  and  are  composed  entirely  of  epidermic  cells. 

Color. — Horns  are  usually  grayish,  yellowish  or  brownish  in 
color.    They  grow  slowly,  years  often  elapsing  before  they  attain 


hernia.  263 

their  full  size.  The  horns  themselves  are  quite  insensitive,  but 
by  pressure  may  give  rise  to  pain.  Sometimes  the  skin  at  their 
base  inflames  and  suppurates  and  they  fall  off  ;  but  they  are  apt 
to  recur  (Anderson). 

Treatment. — Consists  in  tearing  out  the  horn  after  softening 
it  with,  poultices,  but  in  order  to  prevent  its  return,  it  is  desira- 
ble to  cut  out  the  piece  of  skin  from  which  it  grows,  or  to  caut- 
erize the  bases  freely  with  chloride  of  zinc  or  caustic  potash 
(Anderson). 

HERNIA. 

Called  also  rupture,  is  the  protrusion  of  any  viscus  from  its 
natural  or  containing  cavity.  Rupture  is  the  wrong  term,  as 
there  is  no  rupture  of  the  peritoneum;  it  simply  forms  a  sac  or 
one  of  the  coverings.  It  includes  hernise  of  the  brain,  testicle, 
lung,  and  mostly  of  the  alimentary  canal. 

Reasons  for  Studying  Hernia. — 1.  Because  of  its  frequency; 
one  person  in  eight  is  affected  with  hernia.  2.  Because  of  the 
effects  of  the  presence  of  hernia:  (a)  the  individual  cannot  enter 
the  army  or  navy;  (b)  he  must  pay  a  higher  life  insurance;  (c) 
he  cannot  enjoy  the  privileges  of  charity;  (d)  he  is  deprived  of 
many  pleasures. 

Classification. — There  are  ten  varieties,  five  above  the  linea 
ilio  pectinea,  and  five  below  that  line.  The  five  above  are  called 
abdominal  and  are:  1.  Diaphragmatic.  2.  Ventral.  3.  Um- 
bilical. 4.  Inguinal.  5.  Femoral.  The  five  below  are  called 
pelvic  and  are:  1.  Obturator.  2.  Ischiadic.  3.  Vaginal.  4. 
Pudendal.     5.  Perineal. 

The  Component  Parts  of  a  Hernia  are:  1.  Coverings.  2. 
Sac.  3.  Contents.  The  coverings  of  a  hernia  vary  according  to 
the  variety  and  situation.  The  skin,  fascia,  muscle,  subperitoneal 
tissue,  and  peritoneum  cover  all  herniae.  The  sac  always  consists 
of  peritoneum.  It  undergoes  changes  and  may  be  thin  or  very 
thick.  The  sac  is  divided  into  different  parts:  1.  Mouth.  2. 
Neck.  3.  Body.  4.  Fundus.  The  mouth  is  the  opening  be- 
tween the  cavity  and  the  sac.  The  neck  is  the  narrow  con- 
stricted portion  close  to  the  mouth.  The  body  is  the  pari  below 
the  neck.     The  fundus  is  the  largest  portion  of  the  body.  Three 


264  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Muds  of  adhesions  exist:  1.  Adhesions  of  the  guts  to  each  other. 
2.  Adhesions  of  the  guts  to  the  sac.  3.  Adhesions  of  the  sac  to 
the  external  coverings.  The  contents  of  the  sac  may  be  the  ileum, 
colon,  sigmoid  flexure,  or  caecum.  Every  viscus  except  the  pan- 
creas has  been  found  in  the  sac.  Fluid  is  found  in  the  sac,  from 
,one  ounce  to  a  pint.  The  fluid  is  secreted  from  the  sac,  and  is 
generally  clear,  but  is  bloody  in  inflamed  hernia. 

A  hernia  is  named  by  adding  "  ocele  "  to  the  narne  of  the 
body  contained,  or  may  be  named  according^  to  situation. 

Causes.  —  1.  Predisposing.  2.  Exciting. —  Predisposing 
causes  are :  hereditary  conformation  of  the  parts,  34  per  cent,  are 
of  these,  12  per  cent,  of  which  are  in  the  first  year;  structural 
defects,  as  large  inguinal  rings,  lax  peritoneum,  low  attachment 
of  the  mesentary,  wounds  and  abscesses  and  sudden  emaciation 
after  great  corpulence. 

Exciting  Causes  are  :  forced  action  of  the  diaphragmatic 
and  abdominal  muscles,  as  in  straining  at  stool,  lifting  heavy 
weights,  vomiting,  crying,  coughing  in  jmeunionia  or  bronchitis; 
distension  of  the  alimentary  canal;  certain  forms  of  violent  ex- 
ercise, as  horse-back  riding  without  stirrups;  sailors  pulling  at 
ropes,  and  persons  riding  bicycles. 

Signs  and  Symptoms. — By  inspection,  we  observe :  a  tumor 
at  a  hernial  opening;  a  tumor  increasing  and  diminishing  in  size 
and  weight  in  the  upright  and  recumbent  position;  and  a  tumor 
with  healthy  skin  over  it. 

By  examination,  we  find  that  the  tumor  is  reduced  by  taxis 
and  returns  on  coughing;  that  the  tumor  has  an  impulse  on 
coughing  (unless  strangulated);  that  the  tumor  may  be  hard,  re- 
sisting, lobulated  as  in  epiplocele,  or  soft,  elastic  and  smooth  if 
an  enterocele. 

By  inquiry,  we  learn  that  the  tumor  suddenly  appeared 
from  above  and  never  from  below;  that  the  tumor  is  not  painful, 
but  is  uncomfortable;  that  the  tumor  is  often  associated  with 
intestinal  disturbance. 

Diagnosis. — Make  the  patient  stand  before  you  with  his  back 
to  a  table  and  lean  backwards.  If  in  bed  make  him  lie  with  a 
pillow  under  his  nates.  Note  if  the  tumor  is  connected  with  the 
ring.     Place  a  finger  in   the  ring,  through  the   scrotum,  and  ask 


iierxia.  265 

patient  to  cough;  you  will  feel  an  impulse  on  the  end  of  your 
finger.  In  women,  feel  for  the  spine  of  the  pubes  and  pass  your 
finger  up  a  little.  In  femoral  hernia,  feel  for  pulsation  of  the 
femoral  artery  and  ask  the  patient  to  cough.  Inquire  into  the 
history  of  the  patient.  See  if  the  tumor  is  fixed  or  movable. 
Percuss  the  tumor  and  if  intestinal  it  will  be  tympanitic,  if 
epiplocele  dull,  if  solid,  flat.  Hernia  is  not  transparent.  A  hy- 
drocele will  transmit  light  unless  it  contains  blood  or  gut  and 
then  it  is  opaque.  In  hernia  only  there  will  be  an  impulse  on 
coughing. 

Treatment  of  Ordinary  Reducible  Hernia. — Place  the  hernia 
back  into  its  proper  cavity  and  prevent  its  return  by  a  truss. 
A  truss  should  be  used  and  the  following  points  observed  :  1. 
Notice  the  spring — have  it  not  too  weak  or  not  too  strong;  2. 
Notice  the  pad,  it  should  be  covered  with  kid  to  prevent  irrita- 
tion to  the  integument;  3.  Use  a  rubber  truss  in  bathing.  Put 
the  truss  on  while  the  patient  is  lying  down,  as  in  going  to  bed 
at  night  and  rising  in  the  morning.  Hernia  should  be  kept  back 
all  the  time,  and  the  patient  should  never  go  without  a  truss. 
Prof.  Dennis  has  never  seen  a  hernia  which  he  could  not  keep 
back  with  a  truss.  You  should  never  guarantee  a  cure  by  a 
truss,  but  the  younger  the  patient,  the  more  likely  is  he  to  be 
cured  by  the  use  of  a  truss.  The  neck  of  the  sac  contracts  and 
the  mouth  puckers  up.  There  is  danger  in  wearing  a  truss 
which  does  not  fit  properly.  Never  allow  the  hernia  to  be 
pressed.     Never  allow  constipation  to  exist  in  hernia. 

Pathological  Conditions. — There  are  certain  pathological  condi- 
tions which  distinguish  hernise,  as  1.  Irreducible;  2.  Incarcerated: 
3,  Inflamed;  4,  Strangulated. 

An  Irreducible  Hernia  is  caused  by  adhesions,  by  the  nature 
of  the  protrusion,  by  the  shape  of  the  hernia  (hour-glass ),  or  by 
contraction  of  the  ring,  or  of  the  abdomen.  The  symptoms  are 
the  same  as  in  reducible  hernia.  The  tumor  cannot  he  made  to 
go  back  into  the  cavity.  This  form  of  hernia  gives  rise  to  colicky 
pains,  intestinal  derangement,  and  is  liable  to  strangulation.  As 
to  treatment,  the  patient  should  be  carefully  watched.  Let  him 
wear  a  concave  pad  truss.     The   bowels  should  be  moved  daily. 


266  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Give  calomel,  or  iodide  of  potassium,   to  reduce  the  fat  of  the 
patient,  aud  if  then  the  hernia  can  be  reduced,  use  a  truss. 

An  Incarcerated  Hernia  is  an  obstruction  in  the  protrusive 
parts  by  fluid,  solid  or  gaseous  contents.  The  causes  are  diar- 
rhoea, and  faulty  digestion  with  flatulence.  This  form  is  usually 
found  in  elderly  people.  The  signs  are  pain  with  an  increase  in 
the  size  of  the  tumor;  a  certain  degree  of  fullness;  no  heat,  ten- 
derness, or  tension.  The  symptoms  are  eructation  of  gas,  but 
seldom  vomiting;  no  circumscribed  peritonitis;  little  or  no 
pyrexia.  As  to  treatment,  employ  gentle  taxis,  and  as  this  is 
being  done,  jmll  the  tumor  gently  from  the  ring.  Apply  hot 
and  cold  applications  alternately.  Give  an  enema  high  up  in 
the  bowels  of  warm  water,  castile  soap  and  glycerine. 

An  inflamed  hernia  is  an  inflammatory  condition  of  the  gut 
or  the  sac.  The  causes  are  external  violence,  pressure  of  a 
badly  fitting  truss,  local  inflammation  of  the  intestine,  or  of  the 
omentum.  The  signs  are  pain  with  no  enlargement  of  the 
tumor,  a  certain  degree  of  hardness,  heat,  tenderness  and 
tension.  The  symptoms  are,  slight  but  not  continuous  vomit- 
ing, simply  the  contents  of  the  stomach;  circumscribed  peritoni- 
tis radiating  from  the  body  and  neck  of  the  sac;  considerable 
pyrexia.  As  to  treatment,  suspend  the  tumor  and  apply  local 
applications  to  produce  warmth  and  heat  to  the  sac.  Apply 
opium  and  lead  wash  to  the  parts.  Perfect  rest  to  the  bowel 
should  be  insured.  Internally,  give  opium  to  relieve  peristalsis 
and  pain. 

A  strangulated  hernia  is  where  the  sac  or  contents  are  so 
tightly  constricted  that  they  cannot  be  returned  to  the  cavity, 
and  where  circulation  is  arrested.  There  are  two  varieties, 
active  and  passive.  The  active  is  Avhere  the  sac  is  suddenly  en- 
larged, or  the  contents  become  strangulated  with  their  first 
descent.  The  passive  becomes  suddenly  enlarged  by  the  descent 
of  more  intestine  or  omentum,  gas,  fluid  or  solid  into  the  sac. 
Strangulated  hernia  occurs  most  frequently  in  damp  weather. 
The  egression  or  shock  is  due  to  the  sympathetic  nervous 
system  and  not  to  the  cerebro-spinal.  It  simulates  cholera.  In 
all  cases  of  severe,  sudden  illness,  look  for  a  strangulated  hernia. 


heejstia.  267 

The  Local  Signs  are  a  tumor  which  has  either  never  appeared 
before,  or  if  it  has,  is  now  increased  in  size;  a  tumor  which  is 
very  painful,  especially  to  touch,  and  is  irreducible;  a  tumor 
which  has  lost  its  impulse  on  coughing. 

The  Constitutional  Symptoms  are  obstruction  in  the  intes- 
tine with  beginning  symptoms  of  circumscribed  peritonitis;  un- 
controllable vomiting  stercoraceous  in  character,  with  colicky 
pains  radiating  toward  the  umbilicus;  small,  quick,  pulse  associ- 
ated with  great  nervous  prostration.  A  movement  from  the 
bowels  may  take  place  in  strangulated  hernia. 

The  Sructural  Changes  are  as  follows:  The  intestine  be- 
comes first  congested,  then  bright  red,  then  mahogany  brown, 
then  ashen  gray,  then  purulent,  and  then  fibro- purulent.  The 
sac  becomes  inflamed  and  has  a  crackling  sound  and  feel  which 
denotes  gangrene. 

The  Treatment  of  strangulated  hernia  admits  of  no  delay. 
Believe  the  stricture  and  return  the  gut  to  the  cavity  if  it  is 
healthy.  Before  you  employ  taxis,  give  a  hypodermic  injection 
of  sulphate  of  morphine  (in  and  around  the  ring)  to  produce 
quiet  and  relaxation  of  the  parts.  Use  a  warm  bath  to  relax  the 
abdominal  muscles,  and  the  hernia  may  be  reduced  while  in  the 
bath.  This  bath  is  indicated  in  the  active  variety  only.  Vene- 
section may  be  used  to  produce  fainting,  to  relax  the  abdominal 
muscles,  but  this  is  not  advisable  because  danger  may  result. 
Elevate  the  feet  so  as  to  employ  gravitation  toward  the  abdomen. 
Use  aspiration  in  a  tympanitic  gut  to  allow  the  gas  to  escaj3e.  It 
should  never  be  employed  where  the  hernia  is  of  more  than  one 
or  two  hours  standing. 

In  taxis  the  surgeon  must  overcome  all  resistance — flex  the 
legs  and  relax  all  the  muscles.  Invert  the  patient  if  the  hernia 
has  just  happened. 

Operation. — Operate  at  once  if  taxis  has  been  employed  by 
other  surgeons;  the  sooner  the  better.  Employ  taxis  just  before 
the  patient  goes  under  the  anaesthetic.  There  are  four  stages  in 
the  operation:  1.  Exposure  of  the  sac;  2.  Opening  tlie  sac;  3. 
Division  of  the  stricture;  4.  Management  of  the  hernia  after  ex- 
posure. 


268  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

The  incision  should  begin  above  the  external  abdominal 
ring  one  inch,  and  go  to  the  bottom  of  the  scrotum.  Make  the 
line  of  incision  over  the  mesial  line  of  the  tumor.  Cut  through 
the  skin  first  then  the  fascia.  Look  out  next  for  three  vessels, 
viz :  circumflex  iliac,  external  pudic  and  epigastric.  Next  cut 
through  the  external  oblique,  the  internal  oblique,  creruaster  and 
dartos. 

The  peritoneum  is  recognized  by  its  rough  cellular  appear- 
ance, by  its  adhesions  to  surrounding  parts,  by  having  no  blood 
vessels  upon  it,  and  by  its  bluish  color  and  transparency.  The 
intestine  can  be  seen  under  it.  Open  the  sac  at  its  lower  end  by 
taking  it  up  between  forceps.  A  fluid  will  first  appear  which  is 
normal.  Pass  a  director  into  the  opening  audit  will  move  about 
freely  in  the  cavity.  Next  introduce  the  finger  into  the  sac,  the 
finger  having  been  immersed  in  a  bichloride  of  mercury  solution. 
Cut  on  the  finger  to  open  the  sac.  Then  divide  the  stricture  at 
once,  and  examine  the  gut  afterward.  There  are  three  points 
where  strictures  may  be  situated,  at  the  first  ring,  neck  of  the 
sac,  or  within  the  sac.     But  generally  it  is  at  the  ring. 

Protect  the  gut.  Introduce  a  grooved  director  into  the  ring 
and  divide  the  stricture  on  the  director.  If  the  hernia  is  at  the 
abdominal  rings,  cut  upward  and  inward  toward  the  umbilicus. 
If  at  the  umbilicus  cut  toward  the  spleen.  If  at  the  femoral  ring 
cut  inward. 

Do  not  put  back  gut  that  is  gangrenous,  and  do  not  leave 
out  healthy  gut.  Examine  it  carefully,  pull  it  down  to  see  how 
much  of  a  stricture  there  has  been,  and  how  much  damage  is 
done  by  the  stricture.  Note  the  color  of  the  gat.  If  it  is  bright 
red  and  elastic,  it  is  healthy  and  can  go  back.  If  reddish  brown 
or  black,  take  the  thumb  and  index  finger  and  pinch  the  gut  a 
little,  hold  for  a  few  seconds  and  let  go  to  see  if  the  blood  comes 
back  again  to  the  part.  If  so  it  is  healthy.  If  the  gut  is  ashen- 
gray,  collapsed,  and  has  a  cadaverous  odor,  it  is  not  in  a  condi- 
tion to  go  back.  If  the  gut  is  right  to  return,  take  the  thumb 
and  index  finger  and  push  it  back  little  by  little  beginning  at  the 
ring.  In  gangrenous  gut,  let  it  slough  in  the  wound;  because  the 
patient  is  in  collapse,  and  the  gut  is  inflamed,  engorged  and  not 
in  a  proper  condition  to  go  back,  and  the   sac   is  septic,  and  the 


HERNIA.  269 

gut  may  retract  and  then  nature  has  to  fe&tore  the  gut.  If  this 
method  fails  then  later  on  do  resection  open  the  wound  and 
bring  together  the  healthy  ends  of  the  gut.  Keep  the  parts  warm. 
Give  the  patient  morphine  to  keep  the  intestine  quiet.  Do  not 
give,  however,  more  than  two  or  three  doses.  Give  no  food  for 
several  days,  and  then  begin  nourishment  with  peptonized  milk. 
Give  small  pieces  of  ice  to  quench  thirst.  Move  the  bowels  with 
enema  of  olive  oil,  warm  water  and  soap.  Do  not  use  purgatives 
or  cathartics.  The  abdomen  may  be  opened  and  the  gut  relieved 
when  obstructed  with  anything  in  the  way  of  faeces.  When  the 
gut  cannot  be  put  back  with  safety,  use  the  following  treatment: 
Opium,  cracked  ice,  and  milk  diet.  Apply  warmth  to  the  sac. 
Let  the  gut  slough  and  be  drawn  back  into  the  cavity  as  nature 
may  direct.  If  the  peritoneum  has  adhered  to  the  stricture  treat 
it  as  best  you  can. 

Different  Kinds  of  Hernia. 

I.  Diaphragmatic. — Is  a  congenital  hernia  in  which  there 
is  a  fissure  in  the  diaphragm.  When  the  opening  or  rent  in  the 
diaphragm  is  caused  by  malformation,  or  the  arrest  of  develop- 
ment, it  is  a  fatal  condition.  It  may  be  caused  by  traumatism, 
as  the  fracture  of  a  rib,  or  other  injuries,  or  by  the  intestine  go- 
ing through  a  natural  opening  in  the  diaphragm,  on  the  left  side 
because  the  liver  is  on  the  right. 

Treatment — The  first  kind  is  fatal.  The  second  may  be  op- 
erated and  sewed  up.     The  third  demands  no  treatment. 

II.  Ventral. — Is  a  hernia  anywhere  in  the  abdominal  wall, 
except  at  a  hernial  opening,  as  between  the  recti  muscles,  between 
the  ossa  innominata,  between  the  linea  alba  and  the  linea  semi 
lunaris,  and  as  the  result  of  traumatism.  Strangulation  never 
takes  place  in  hernia  due  to  traumatism.  It  usually  follows  lap- 
arotomy. 

Treatment. — If  the  hernia  is  great  cut  in  and  stitch  the  per- 
itoneum first  and  then  the  soft  parts  over  it. 

III.  Umbilical. — Is  a  hernia  where  the  cord  is  tied.  It  is 
caused  by  a  malformation  and  comes  in  early  life.  It  is  also 
caused  by  the  exertion  of  the  infant.  One  kind  may  be  situated 
above  the  umbilicus  in  the  adult  and  not  in  it. 


270  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment  — In  children  treat  the  hernia  with  a  truss  and  one 
suitable  for  the  purpose.  In  adults,  a  hernia  above  the  umbili- 
cus is  dangerous  and  is  liable  to  strangulation.  If  this  occurs 
the  patient  is  most  certain  to  die.  If  the  patient  does  not  die, 
he  will  have  indigestion,  which  must  be  distinguished  from  acute 
indigestion  and  can  be  by  persistent  vomiting  in  hernia.  It  oc- 
curs four  times  in  the  female  to  once  in  the  male. 

IV.  Inguinal.  Varieties. — 1.  Indirect  inguinal  hernia,  or 
external,  is  one  that  goes  through  the  inguinal  canal.  2.  Direct 
inguinal  hernia,  or  internal,  is  one  that  makes  its  way  directly 
through  the  external  ring  without  having  passed  down  the  in- 
guinal canal.  When  the  protrusion  takes  place  above  Poupart's 
ligament,  through  the  intestinal  ring,  but  does  not  traverse  the 
canal  sufficiently  far  to  appear  through  the  external  ring,  the 
hernia  is  called  a  bubonocele.  Indirect  inguinal  is  also  called 
oblique  inguinal  hernia. 

Occurrence. — Three-fourths  of  all  cases  of  inguinal  hernia 
are  on  the  right  side  of  the  body,  because  the  liver  is  pressing 
above,  and  the  root  of  the  mesentary  is  lower  down  on  that  side, 
and  most  persons  are  right  handed.  It  is  more  common  in  males 
than  in  females,  because  the  rings  are  larger.  Out  of  every  100 
cases  of  hernia,  84  are  inguinal,  10  femoral,  and  5  umbilical. 
When  an  inguinal  hernia  protrudes  through  the  external  ring 
into  the  scrotum,  it  is  called  a  scrotal  hernia.  The  tissues  that 
cover  in  a  hernial  sac  will  necessarily  depend  upon  the  seat  of 
the  hernia. 

The  treatment  is  the  same  as  in  other  hernia. 

V.  Femoral. — Is  a  hernia  below  Pouparfs  ligament,  the  pro- 
trusion having  come  down  through  the  crural  ring  on  the  inner 
side  of  the  sheath  of  the  femoral  vessels.  It  does  not  appear  at 
birth,  nor  in  early  life — about  twenty  years  of  age.  It  is  more 
frequent  in  women  than  in  men,  because  Poupart's  ligament  is 
longer  and  weaker,  and  the  pelvis  is  wider  in  women.  The  neck 
of  the  sac  appears  beneath  Poupart's  ligament  and  the  fundus 
rolls  up  over  it. 

Treatment. — Femoral  hernia  requires  an  immediate  opera- 
tion. The  neck  of  the  sac  is  surrounded  by  ligamentous  tissue 
which  is  unyielding  and  the  danger  is  great. 


HERNIA.  271 

VI.  Ohturator. — Is  a  hernia  which  comes  out  through  the 
obturator  foramen.  It  is  most  frequent  in  females  on  account  of 
the  greater  inclination  of  the  pelvis. 

Signs  and  Symptoms. — There  is  a  tumor  at  the  inner  side  of 
the  thigh  and  femoral  vessels.  There  is  pain  in  the  knee  joint 
owing  to  pressure  of  the  tumor  on  the  obturator  nerve,  and  the 
pain  is  increased  by  extending  the  leg,  and  by  rotating  the  thigh 
outwards.     Other  signs  are  the  same  as  in  any  other  hernia. 

Treatment. — Gentle  taxis  is  generally  sufficient.  It  often 
becomes  strangulated. 

VII.  Ischiatic. — Is  a  hernia  which  comes  out  through  the 
ischiatic  notch,  above  or  below  the  pyriform  muscle,  and  under 
cover  of  the  gluteus  maximus. 

Symptoms. — Same  as  in  any  other  hernia  with  one  extra — a 
tumor  found  on  a  line  drawn  from  the  trochanter  major  to  the 
sacro- iliac  synchondrosis. 

Treatment. — Careful  taxis.     If  strangulated  operate. 

VIII.  Vaginal. — Is  a  protrusion  at  the  upper  and  posterior 
part  of  the  vagina.     It  comes  usually  after  parturition. 

Symptoms. — Has  all  the  signs  of  inguinal  hernia  and  an 
impulse  on  coughing.  It  is  a  smooth,  soft  tumor  increasing  in 
the  upright  and  decreasing  in  the  recumbent  position.  It  causes 
tenesmus  and  cystitis.     It  is  reduced  by  taxis. 

Diagnosis.— It  may  be  mistaken  for  cystocele.  The  diag- 
nosis is  made  by  introducing  a  male  sound.  It  does  not  become 
strangulated. 

Treatment. — It  is  easily  reduced  and  kept  back  by  a  ring 
pessary.     It  should  be  reduced  before  labor.   , 

IX.  Pudendal. — Begins  like  vaginal.  Comes  out  between 
the  vagina  and  the  levator  ani  muscle,  lies  in  the  long  axis  of 
the  vagina,  presents  at  the  side  of  the  ascending  ramus  of  the 
ischium. 

Treatment. — It  is  easily  reduced  and  kept  back  by  a  truss. 

X.  Perineal. — Is  a  hernia  between  the  rectum  and  bladder 
in  the  male,  or  between  the  rectum  and  vagina  in  the  female.  It 
is  more  frequent  in  the  female  on  account  of  a  greater  pelvis. 

Signs. — Are  the  ordinary  ones.  It  forms  a  tumor  between 
the  tuber-ischii,  which  increases  in  size  when  standing. 


272  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — Use  a  special  perineal  truss  after  reducing  it. 
Tumors  Which  Are  Confounded  with  Hernia. — 1.  Hydrocele. 

2.  Spermatocele.     3.   Hcematocele.      4.    Varicocele.      5.    Undes- 
cended Testicle.     6.  Solid  Tumor  of  Testicle.     7.  Abscess. 

I.     Hydrocele. — 

Signs. — 1.  Slow  growth  from  below  upwards.  2.  It  has  a 
tense  elastic  feel.  •  3.  Transparency.  4.  Absence  of  impulse  on 
coughing. 

IT.     Spermatocele. — 

Signs. — 1.  Situated  above  the  testicle.  2.  Notched  appear- 
ance from  pressure  on  the  cord.  3.  Marked  mental  effect.  4. 
Sj^ermatozoa  seen  under  the  microscope. 

Ill     Hcern  a  tocele. — 

Signs. — Sudden  growth  following  traumatism.  2.  Soft  fluc- 
tuating feel.  3.  Ecchymosis  of  scrotum,  pain  and  tenderness. 
4.   Irreducibility. 

IV.      Varicocele. — 

Signs. — 1.  Slow  growth  from  below  upwards.  2.  Feels 
similar  to  a  bag  of  worms.  3.  Reducible,  but  will  return  with 
pressure  over  ring.     4.  It  does  not  involve  the  spermatic  cord. 

V.      Undescended  Testicle. — 

Signs. — 1.    Testicular    sensation.     2.   Pain    upon    j^ressure. 

3.  Absence  of  a  testicle  in  the  scrotum.     4.  Absence  of  an  im- 
pulse on  coughing. 

VI  Tumor  of  Testicle. — 

Signs. — 1.  Circumscribed  size.  2.  Doughy,  lobulated  feel. 
3.  Constant  situation  below  inguinal  canal.  4.  Absence  of  an 
impulse  on  coughing. 

VII  Abscess. — 

Signs. — 1.  Sense  of  fluctuation.  2.  Inflamed  integument. 
3.  Returns  without  a  gurgle.     4.  Peculiar  impulse  on  coughing. 

HYDRONEPHROSIS. 

Called,  also,  dropsy  of  the  kidney,  consists  of  an  accumula- 
tion of  urine  and  dilatation  of  the  pelvis  and  calices,  with  pro- 
gressive atrophy  of  the  renal  structure  (Bartholow). 

Causes. — It  is  caused  by  some  obstruction  in  the  urinary 
passages.     The  obstruction  may  be  seated  in  the  bladder,  pelvis, 


HYDRONEPHROSIS.  273 

ureter,  bladder,  or  urethra.  It  is  usually  unilateral.  It  may  be  con- 
genital or  acquired.  Congenital  causes  are:  1.  A  supernumerary 
renal  artery  compressing  the  ureter.  2.  Narrowing  of  the  lumen 
of  the  ureter.  3.  A  valve-like  impediment  produced  by  an 
oblique  insertion  of  the  ureter  into  the  pelvis  of  the  kidney. 
4.  Insertion  of  the  ureter  into  the  upper,  instead  of  the  lower 
part  of  the  pelvis.  The  congenital  is  often  associated  with  mal- 
formations of  other  parts,  as  imperforate  anus,  hare -lip,  etc. 

The  acquired  causes  are  :  1.  The  ureter  may  be  blocked  by 
a  calculus,  by  coagula  of  blood,  or  by  parasites.  2.  Diseases  of 
the  walls  of  the  ureters.  3.  Pressure  upon  the  ureter  from 
without,  by  a  tumor,  by  a  displaced  uterus,  etc.  4.  Diseases  of 
the  bladder  which  involve  one  or  both  of  the  orifices  of  the 
ureters.  5.  Stricture  and  hypertrophy  of  the  prostate  (Bartholow, 
Loomis  and  Flint). 

Symptoms.- — An  important  diagnostic  sign  is  the  discovery 
of  a  tumor  in  the  lumbar  region.  The  tumor  is  fluctuating  and 
usually  lobulated.  It  causes  no  pain  except  by  its  pressure.  In 
growing,  adhesions  form  which  give  rise  to  acute  stabbing  pains 
at  the  time  of  their  formation.  If  the  tumor  presses  upon  the 
colon,  constipation  results;  if  upon  the  diaphragm,  dyspnoea  will 
result;  if  upon  the  stomach,  there  will  be  nausea  and  vomiting; 
if  the  tumor  rests  upon  the  abdominal  aorta,  a  pulsation  will  be 
communicated  to  it.  A  symptom  of  almost  pathognomonic  value 
is  the  disappearance  of  the  tumor  coincident  with  the  discharge 
of  a  large  quantity  of  pale  liquid  by  the  bladder.  The  course  of 
the  disease  is  chronic,  and  the  formation  of  the  tumor  slow  (Bar- 
tholow, Loomis  and  Flint). 

Differential  Diagnosis. — Hydronephrosis  may  be  confounded 
with  ovarian  cysts,  ascites,  hydatid  cysts  and  pyonephrosis.  In 
ovarian  cysts,  the  tumor  develops  from  below.  Vaginal  and 
rectal  examinations  will  aid.  In  ascites,  when  the  position  of 
the  patient  is  changed  there  is  a  change  in  the  level  of  dullness, 
which  never  occurs  in  hydronephrosis.  It  cannot  be  distinguished 
from  hydatid  cysts  unless  hydatid  vessels  are  found  in  the  urine. 
It  is  distinguished  from  pyonephrosis  by  a  non-purulent  charac- 
ter of  the  urine,  and  by  the  absence  of  constitutional  symptoms. 

Treatment. — Remove  the   cause   of  obstruction  if  possible. 


274  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Removal  of  the  liquid  by  aspiration  has  rji'ovecl  successful.  A 
small  aspirating  needle  or  trocar  should  be  used.  Free  opening 
and  drainage  is  a  favorable  surgical  procedure.  Medicine  will 
accomplish  nothing. 

HYDROPHOBIA. 

Called,  also,  rabies,  is  a  specific  disease  due  to  the  inocula- 
tion of  a  poison  contained  in  the  saliva  of  rabid  animals,  notably 
the  dog,  and  characterized  by  pain  and  stiffness  of  the  inoculated 
part;  by  exaltation  of  the  reflex  faculty,  by  spasms  of  the  throat 
on  the  attempts  to  swallow,  and  subsequently  at  the  sight  of 
liquids;  by  delirium,  exhaustion  and  death  (Bartholow). 

Causes. — The  inoculation  of  man  with  a  specific  virus  con- 
tained in  the  saliva  of  the  dog,  cat,  wolf,  fox,  and  some  other 
rabid  animals,  is  the  sole  cause  of  the  disease.  A  certain  predis- 
position seems  necessary,  for,  of  all  persons  bitten  by  rabid 
animals,  onlv  a  small  proportion  are  attached  by  hydrophobia. 
The  teeth,  in  inflicting  the  wound,  pass  through  the  clothing, 
which  removes  the  saliva,  and  therefore  the  most  of  those  bitten 
through  the  clothing  escape  infection.  All  ages  and  both  sexes 
are  liable.  Apprehension,  fear,  excesses  of  all  kinds,  fatigue, 
etc.,  favor  the  occurrence  of  the  disease  (Bartholow). 

Symptoms. — The  period  of  incubation  varies  from  a  few  days 
to  several  months  or  even  years.  During  the  invasion  of  the 
disease  if  the  wound  has  not  healed,  it  takes  on  a  livid  appear- 
ance, and  becomes  painful ;  if  it  has  healed,  the  scar  becomes  red, 
irritable,  swollen  and  painful.  Sometimes  a  sensation  of  cold- 
ness and  of  numbness  is  felt  in  the  bitten  member.  These  local 
symptoms  are  soon  followed  by  systemic  disturbances.  The  pa- 
tient is  depressed,  apprehensive,  melancholic  and  peevish.  The 
first  is  called  the  melancholic  stage.  There  may  be  slight  con- 
striction of  the  throat,  and  difficult  swallowing.  These  symp- 
toms increase  in  severity  for  two  or  three  days,  when  the  patient 
passes  into  the  convulsive  stage.  In  this  stage,  there  is  great 
restlessness,  the  eyes  have  a  wild  look,  are  bright,  staring,  and 
constantly  moving.  The  mouth  and  throat  are  dry,  congested, 
and  covered  with  thick,  tenacious  saliva  which  gathers  about  the 
lips  in  frothy  masses. 


HYDROPHOBIA ICHTHYOSIS.  275 

Thirst  is  intense,  but  the  patient  cannot  drink.  The  sight 
of  water,  or  the  thought  of  drinking  brings  on  violent  spasms  of 
the  muscles  of  deglutition  and  respiration.  There  is  intense 
hyperesthesia,  and  convulsions  follow  attempts  at  drinking.  In 
rare  cases  there  is  a  paraplegic  stage.  The  hawking  and  spitting 
of  the  patient  seems  like  the  bark  of  a  dog.  Patients  often  be- 
come violent. 

Duration. — Hydrophobia  is  a  very  acute  disease.  The  whole 
duration  of  the  disease  is  comprehended  in  three  days  to  two 
weeks  (Bartholow  andLoomis). 

Prognosis. — Is  most  unfavorable. 

Treatment. — When  the  bite  of  a  rabid  animal  has  been  re- 
ceived, the  wound  should  be  scarified,  cauterized  with  a  hot  iron, 
or  every  part  of  it  touched  with  nitrate  of  silver.  Permanganate 
of  potassium  should  be  tried.  There  is  no  specific  to  prevent 
the  disease,  unless  Pasteur's  inoculations  with  the  modified  virus, 
have  this  power.  Of  all  the  remedies  proposed,  curare  is  the 
only  one  which  seems  to  possess  any  power  over  hydrophobia. 
One-third  grain  should  be  given  every  fifteen  minutes  (Bartholow 
and  Loomis). 

ICHTHYOSIS. 

Called,  also,  fish- skin  disease,  is  a  rare  malady.  It  is  not  so 
much  a  disease  as  a  deformity. 

Causes. — The  cause  is  unknown. 

Symptoms. — There  is  excessive  proliferation  of  the  cells  of 
the  epidermis.  The  skin  is  thickened,  dry,  coarse,  wrinkled,  and 
discolored.  There  is  defective  action  of  the  sudoriparous  and 
sebaceous  glands.  The  scales  resemble  those  of  a  fish  (An- 
derson). 

Treatment. — A  long  course  of  arsenic  is  useful.  The  hypo- 
dermic injection  of  ^  of  a  grain  of  pilocarpine  may  be  used  from 
time  to  time.  The  local  treatment  consists  in  the  frequent  use 
of  baths.  Oily  substances  may  be  applied  to  the  skin  to  keep  it 
soft  (Anderson). 


276  A   -COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  ICHTHYOSIS. 

R     Cupri  sulphatis gr.  x. 

Unguenti  sambuci  §j. — M. 

Sig. :     Use  locally.  — Wilson. 

R     Pulv.  camphora? gr.  x. 

Ungt.  zinci  oxidi 5J. — M. 

Ft.  Ungt. 

Sig.:     Use  locally.  — Erasmus  Wilson. 

R     Ulmi  corticis ^iiss. 

Aquae  bullien tis Oj . — M. 

Ft.  haustus. 
Sig.:     A  wineglassful  or  two  thrice  daily.  — Lettson. 

IMPETIGO. 

Is  an  acute  pustular,  inflammatory  cutaneous  disease.  It  is 
the  pustular  form  of  eczema.     (See  eczema.) 

Treatment. — The  glycerite  of  tannin  is  an  excellent  applica- 
tion for  impetigo.  Skin- diseases,  as  impetigo  and  ecthyma, 
usually  arising  from  a  feeble  state  of  the  assimilative  function, 
are  cured  by  quinine.  Nitric  and  nitro -hydrochloric  acids  have 
been  used  with  advantage  for  the  cure  of  impetigo,  when  depend- 
ent upon  indigestion  (Bartholow). 

PRESCRIPTIONS  FOR  IMPETIGO, 

R     Plumbi  acetatis gr.  xv. 

Acidi  hydrocyan  clil  , ITIxx. 

Alcoholis §ss. 

Aqua? §vss. — M. 

Sig.:     Apply  locally.  — Bartholow. 

R     Zinci  oxidi 31J. 

Glycerinas 5ij. 

Liq.  plumbi  subacetatis 3iss- 

Aquae  calcis ad syj. — M. 

Sig.:     Apply  locally.  — Fox. 

R     Unguenti  zinci  oxidi §j. 

Sig.:     Apply  locally.  — Ringer. 

R     Syrupi  hypophosphiti  comp svi. 

Sig.:     A  teaspoonml  thrice  daily  in  water.  — Jamieson. 


INDIGESTION INFLAMMATION.  277 

INDIGESTION.     (See  Dyspepsia). 

INFLAMMATION. 

Is  that  nutritive  disturbance  which  is  characterized  by  ac- 
tive hyperemia  or  congestion,  and  active  multiplication  or  pro- 
liferation of  the  cells  of  a  tissue  or  organ  (Gross). 

Causes.— Are  predisposing  and  exciting.  The  predisposing 
are  gout,  syphilis,  scrofula,  shock,  loss  of  blood,  impaired  nerv- 
ous action,  bad  habits,  diabetes,  anaemia,  etc.  The  exciting 
causes  are  cold  or  heat,  injuries,  acid  or  alkalies,  parasites, 
and  the  results  of  the  ptomaines  of  micro-organisms  on  the  tis- 
sues. 

Symptoms. — A  part  is  acutely  inflamed  when  it  is  hot,  red, 
swollen  and  painful.  The  local  symptoms  are  :  1.  Redness,  which 
is  caused  by  an  afflux  of  blood  to  the  part.  Redness  is  not  al- 
ways a  sign  of  inflammation,  unless  it  be  permanent.  2.  Heat, 
which  is  always  present,  and  is  due  to  an  iu creased  flow  of  blood 
to  friction  against  the  walls  of  the  vessels  of  the  part  and  to  cell 
proliferation.  The  inflamed  part  is  a  heat-producing  area,  thus 
causing  fever  by  overheating  the  blood.  3.  Swelling,  which  is 
due  to  capillary  engorgement,  and  effusion  of  serum  into  the  tis- 
sues. The  swelling  is  greater  where  the  tissues  are  lax.  And 
4.  Pain,  which  is  usually  felt  at  the  seat  of  the  morbid  action. 
Pain  sometimes  suddenly  leaves  a  part,  which  is  a  sign  of  com- 
mencing mortification.  The  causes  of  pain,  are  compression, 
stretching,  irritation  and  disorganization  of  nerves.  Its  charac- 
ter varies;  it  may  be  sharp  and  lancinating,  as  in  inflammation  of 
serous  membranes;  acute  and  throbbing,  as  in  formation  of  pus; 
dull  and  heavy,  as  in  periostitis;  annoying,  as  in  toothache;  sick- 
ening, as  inflammation  of  the  testes,  itching,  as  in  affections  of 
the  skin;  or  burning  and  scalding,  as  in  gonorrhoea.  The  pain 
in  inflammation  comes  on  gradually,  is  persistent,  aggravated  by 
pressure  and  muscular  contraction,  and  is  fixed;  there  is  febrile 
disturbance,  accompanied  by  redness,  heat  and  swelling.  The 
pain  of  spasm  comes  on  suddenly,  is  intermittent,  relieved  by  pres- 
sure; is  not  fixed,  there  is  no  fever,  and  is  not  accompanied  by 
redness,  heat  or  swelling.  Theofpain  neuralgia  is  paroxysmal,  is 


278  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

aggravated  by  pressure,  is  not  fixed,   and  is   unaccompanied  by 
fever,  redness,  heat  or  swelling. 

Constitutional  Symptoms. — In  mild  cases  there  is  no  consti- 
tutional disturbance,  but  if  the  inflammation  be  at  all  severe, 
fever  will  follow.  The  fever  is  usually  ushered  in  with  a  chill. 
The  tongue  becomes  furred  and  unclean,  there  is  great  thirst, 
want  of  appetite,  the  bowels  are  constipated,  the  urine  is  scanty, 
the  skin  hot  and  dry,  and  the  heart's  action  increased  (Coin- 
pend). 

Products  of  Inflammation. — Are  fibrin,  serum,  pus  cells  and 
red  blood- corpuscles.  The  first  effect  of  the  application  of  an 
inflammatory  irritant  is  a  dilatation  of  the  arteries,  then  of  the 
veins,  and  last  of  all,  of  the  capillaries.  At  the  same  time  the 
velocity  of  the  blood- current  is  increased.  After  a  time  the  blood 
flows  less  rapidly,  and  in  the  capillaries  it  may  come  to  a  com- 
plete stagnation  or  stasis.  At  this  time  the  white  corpuscles 
migrate  from  the  veins  and  capillaries,  but  not  from  the  arteries. 
The  red  corpuscles  pass  through  the  capillary  walls  by  a  process 
known  as  diapedesis  (Flint). 

Treatment. — Remove  the  exciting  cause  if  possible.  The 
general  treatment  is  rest  and  elevation  and  relaxation  of  the 
affected  part.  The  local  treatment  in  the  stage  of  congestion  is 
bleeding.  This  may  be  affected  by  punctures,  scarifications, 
leeching,  or  cupping.  Leeches  should  not  be  put  on  the  inflamed 
surface,  but  between  the  inflamed  part  and  the  heart.  If  it  is 
desired  to  remove  a  leech  after  a  certain  time,  this  may  be  ac- 
complished by  sprinkling  salt  upon  it.  The  bleeding  may  be 
stopped  by  applying  to  the  part  nitrate  of  silver,  muriated  tinc- 
ture of  iron,  or  styptic  cotton.  The  flow  of  blood  from  a  leech - 
bite  may  be  continued  by  the  application  of  warm  water.  The 
application  of  cold  is  frequently  of  service.  It  contracts  the 
calibre  of  the  capillaries.  When  the  second  stage,  or  that  of  effu- 
sion, is  established,  compression  by  bandages  is  useful.  Acetate 
of  lead  is  applicable  to  all  cases  of  external  inflammation  (eight 
grains  to  an  ounce  of  water).  When  the  third  stage,  or  that  of 
suppuration,  is  reached,  the  application  of  heat  and  moisture  by 
means  of  warm  baths  and  poultices  is  the  best. 

Constitutional    Treatment. — In  strong,    robust  individuals, 


INFLAMMATION— IMPOTENCE.  279 

blood-letting  may  be  resorted  to  in  the  first  stage  of  inflamma- 
tion. Arterial  sedatives  such  as  tincture  of  veratrum  viride, 
aconite  root,  gelsemium  and  tartar  emetic  are  indicated  in  the 
first  stage  of  inflammation.  The  diaphoretics  in  general  use  are 
acetate  of  ammonium,  citrate  of  potassium,  Dover's  powders, 
fluid  extract  of  jaborandi,  muriate  of  pilocarpine  and  lemon 
juice  with  bicarbonate  of  potassium.  The  diuretics  in  use  are 
infusion  of  digitalis,  salts  of  potassium,  citrate  of  caffein,  coffee, 
etc.  Cathartics  are  used  to  evacuate  the  bowels,  deplete  the 
mucous  membrane,  and  to  stimulate  the  absorbents,  and  thereby 
remove  the  inflammatory  deposit.  Enemata  of  warm  water,  or 
soap  and  water  may  be  used  to  unload  the  bowels.  Emetics  are 
indicated  when  the  skin  is  hot  and  dry,  the  tongue  heavily  coated, 
and  great  weight  in  the  epigastrium.  Anodynes.— Opium  is 
applicable  to  the  treatment  of  inflammation  in  all  stages  of  the 
disease.  It  should  be  preceded  by  a  cathartic.  It  must  be  given 
in  full  closes,  as  small  doses  act  as  stimulants,  while  larger  doses 
act  as  sedatives.  Hypnotics. — When  the  patient  is  restless,  but 
not  suffering  acute  pain,  hypnotics  are  indicated,  such  as  bromide 
of  potassium  gr.  xxx.,  chloral  gr.  xx.,  taken  at  bedtime 
(Compend). 

IMPOTENCE, 

Is  a  symptom,  and  means  inability  to  perform  the  act  of 
coition.  Impotence  must  be  carefully  distinguished  from  steril- 
ity, which  signifies  inability  to  beget  offspring  on  account  of 
defect  in  the  semen,  whether  the  individual  can  have  sexual  in- 
tercourse properly  or  not.  A  man  may  be  impotent  and  virile, 
or  impotent  and  sterile,  or  potent  and  sterile. 

The  sexual  act  is  a  compound  one,  physical  and  mental. 
The  physical  organs  may  be  perfect  and  capable  in  their  way; 
but  if  the  mental  are  deficient  in  energy,  or  weakened  by  doubt 
of  competency,  or  under  the  influence  of  some  emotion  such  as 
shame  or  fear,  the  sexual  act  will  be  spoilt,  and  failure  to  com- 
plete it  must  ensue. 

Impotence  may  involve  absence  of  sexual  desire,  or  it  may 
exist  without  loss  of  sexual  desire.  Different  persons  in  health 
differ  widely  as  regards  the  venereal  propensity;   in  some  persona 


280  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  sexual  desire  is  intense,  in  others  it  is  feeble  and  sometimes 
wanting.  The  propensity  may  be  increased  by  indulgence  and 
diminished  by  an  opposite  course.  In  the  marital  relation  cold- 
ness may  depend  on  personal  antipathy  and  is  a  frequent  source 
of  domestic  unhappiness  (Bryant  and  Flint). 

ImpoteDce  may  be  considered  as  true  and  false.  True  im- 
potence is  exceedingly  rare  in  the  male. 

Causes. — 1.  Absence  of  penis.  2.  Minute  size  of  penis  is 
only  a  relative  cause.  3.  Extreme  size  of  the  penis  is  a  relative 
cause.  4.  Extreme  epispadias  and  hypospadias.  5.  Large  size 
of  the  prepuce,  tight  and  narrow  orifice,  tumors  or  growths  upon 
or  about  the  penis,  and  excess  of  abdominal  fat.  6.  Very  tight 
stricture  of  the  urethra.  7.  Aspermatism.  8.  Imperfect,  irreg- 
ular and  bent  erections.  9.  Eunuchs.  10.  Prolonged  sperma- 
torrhoea. 11.  Partial  erection,  attended  by  rapid  ejaculation,  is 
a  common  variety  of  impotence,  due  usually  to  continence, 
over- excitement,  etc.  In  this  case,  the  patient  should  practice 
the  sexual  act  in  the  early  morning  rather  than  the  evening. 
Circumcision  may  sometimes  be  necessary  to  diminish  the  sensi- 
tiveness of  the  glans  penis,  which  is  often  over -acute. 

Treatment. — Remove  the  cause  if  possible. 

FALSE  IMPOTENCE. 

Causes. — In  false  impotence,  the  cause  is  always  nervous,  or 
it  may  be  a  moral  one;  and  there  is  often  no  impotence  at  all, 
except  in  the  mind  of  the  individual.  Sexual  indifference,  as  a 
result  of  sudden  shock,  grief,  excessive  joy,  fright,  repugnance 
and  lack  of  affection  for  the  individual,  is  a  cause.  Under  the 
two  latter  circumstances  the  patient  will  sometimes  think  of  an- 
other person  than  the  one  with  whom  he  is  lying,  and  thus  main- 
tain erection  and  effect  ejaculation.  The  sudden  flooding  of  the 
vagina  with  warm  mucus  will  sometimes  cause  erection  to  cease 
.at  once.  Rouband  speaks  of  a  man  who  became  impotent  on 
drawing  a  prize  of  thirty  thousand  francs  in  a  lottery.  The 
same  author  mentions  another  curious  cause  of  false  impotence : 
A  young  man  brought  up  in  the  country  was,  at  the  age  of  four- 
teen, initiated  into  the  mysteries  of  Venus,  by  a  young  friend  of 


IMPOTENCE.  281 

the  family,  twenty- one  years  old.  Her  hair  was  light,  and  worn 
in  curls,  and  for  precaution's  sake',  she  never  had  intercourse 
with  the  boy  except  when  dressed — that  is,  wearing  a  corset, 
high  boots  and  a  silk  dress.  A  dark  beauty  had  no  power  over 
him,  and  a  night-dress  extinguished  all  his  fire.  In  after  life,  he 
found  himself  utterly  impotent  except  in  the  company  of  a  light 
haired  woman,  wearing  curls,  with  high  hoots,  a  corset  and  a  silk 
dress  (Keyes). 

Treatment. — It  is  necessary  to  arouse  the  moral  sentiment  of 
carnal  desire  by  favorable  relations  to  the  sex — opera,  theatre,  etc. 
The  power  of  the  organs  is  increased  by  general  dry  friction  of 
the  whole  body,  by  massage  and  flesh-brush,  cold- bath,  sea- 
bathing, generous  diet,  tonics,  the  mineral  acids,  strychnine,  er- 
got, and  especially  phosphorus  and  cantharides,  or  the  two  com- 
bined, commencing  at  a  fair  dose,  one -fortieth  of  a  grain  of  the 
former  to  ten  drops  of  the  tincture  of  the  latter,  three  or  four 
hours  before  the  desired  erection,  and  increasing  the  dose  care- 
fully. Cantharides  produces  erection  without  desire,  and  phos- 
phorus with  desire.  Electricity,  and  local  applications  of  mus- 
tard are  sometimes  serviceable  in  recalling  erection. 

Nervous  Impotence. — Is  the  most  common  form  of  false  im- 
potence. It  occurs  in  young  men.  The  patient  can  provoke 
erection  at  will  and  awakes  with  erection,  but  when  in  the  pres-- 
ence  of  a  woman,  and  when  he  desires  to  have  sexual  intercourse, 
his  organs  will  not  respond,  or  if  erection  comes  on,  it  lacks  full 
energy. 

Causes. — This  form  of  impotence  is  the  result  of  unnatural 
excitement  of  the  sexual  functions.  It  may  come  from  protracted 
chastity,  ungratified  desire,  or  excessive  erotic  excitement  at  the 
time.  After  prolonged  chastity  and  great  desire,  the  sufferer  has 
probably  approached  a  female,  and  at  the  portals  of  success  his 
erection  has  failed  him.  The  mental  depression  following  an 
exjDerience  of  this  sort  is  of  the  most  exaggerated  nature.  He 
thinks  he  is  impotent  beyond  all  doubt.  The  cunningly  con- 
ceived advertisements  of  charlatans  in  newspapers  envelop  him 
further  in  deep  despair.  He  is  now  without  a  ray  of  hoj3e 
(Keyes). 

Treatment. — The  best  treatment  for  a  man  with  nervous  im- 


282  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

potence  is  to  instruct  nini  in  sexual  physiology  and  hygiene,  and 
get  him  married,  with  the  advice  to  attempt  no  intercourse,  and 
awaiting  some  morning  when  awakening  with  a  vigorous  erec- 
tion, to  accomplish  coitus  promptly,  without  delay  or  dalliance. 
The  act  once  accomplished  the  charm  is  broken.  The  use  of  the 
steel  sound  and  of  local  applications  of  tannin,  often  of  decided 
service  where  ejaculation  is  too  rapid,  are  also  sometimes  useful 

here  (Keves). 

PRESCRIPTIONS  FOR  IMPOTENCE. 

R     Tinct  sanguinariffi , giij. 

Ext.  stillingise  fid 5v. — M. 

Sig. :     Fifteen  or  twenty  drops  in  water  thrice  daily. 

— Bartholow. 

R     Zinci  phosphidi gr.  ij. 

Confect  rosee gr.  xx. 

Sig.:     One  to  three  pills  three  times  daily.  — Bartholow. 

R     Ext.  cannabis  indica? 

Ext.  nucis  vomicae aa gr.  xv. 

Ext.  ergotse  aquosi ..•••3J- — M. 

Ft.  massa  et.  in  pil.  no.  xxx.  div. 
Sig. :     A  pill  morning  and  evening.  — DaCosta. 

R     Tinct.  phosphori giss. 

Tinct.  cantharides ^iijss. 

Elixir  simplicis  ad §v. — M. 

Sig. :     One  teaspoonful  three  or  four  hours  before  retiring.      In- 
crease dose  carefully.  — Van  Buren  and  Keyes. 

INCONTINENCE  OF  URINE.     (See  Enuresis). 

INFLUENZA. 

Called  also  epidemic  catarrh,  la  grippe  and  catarrhal  fever, 
is  a  specific  epidemic  disease,  self -limited,  characterized  by  ca- 
tarrh of  the  respiratory  organs,  and  sometimes  of  the  digestive, 
and  by  nervous  symptoms  and  debility  (Bartholow).  In  1830 
and  1831  a  severe  influenza  epidemic  swept  over  the  whole  civ- 
ilized world  (Loomis ) . 

Causes. — All  conditions  and  all  ages  suffer  alike.  The  dis- 
ease has  passed  over  the  whole  of  Europe  in  six  weeks.  It  rarely 
continues  in  one  locality  more  than  two  months.  The  usual  dur- 


influenza.  283 

ation  of  an  epidemic  is  two  to  four  years.     It  seems  to  be  clue  to 
some  special  morbific  principle  in  the  atmosphere  (Loomis). 

Symptoms. — Influenza  comes  on  suddenly.  A  feeling  of 
chilliness,  flashes  of  heat,  and  a  feeling  of  lassitude  are  followed 
by  symptoms  of  a  severe  naso- pharyngeal  catarrh,  with  frontal 
headache,  j)ains  in  the  limbs  and  back,  soreness  of  the  throat, 
hoarseness  and  a  frequent  racking  cough,  difficult  breathing  and 
constriction  across  the  chest.  The  sputa  are  at  first  mucous 
and  then  scanty,  later  copious  and  muco- purulent.  There  is  great 
prostration.  Sudamina  appear  on  the  surface  and  herpes  on  the 
lips.  There  is  anorexia.  There  may  be  nausea  and  vomiting. 
The  face  becomes  congested  and  livid,  the  pulse  increases,  the 
tongue  becomes  dry  and  brown,  and  the  temperature  rises.  In 
mild  cases  the  disease  is  at  its  height  on  the  third  day.  In  severe 
cases,  convalescence  does  not  commence  until  the  tenth  or  twelfth 
day  (Loomis). 

Prognosis. — Is  good  except  in  the  very  old,  very  young,  and 
the  debilitated.  Complications  make  the  prognosis  graver.  The 
most  frequent  complications  are  laryngitis,  bronchitis,  pulmo- 
nary congestion,  pneumonia  and  pleurisy.  Herpes  labialis 
occurs  often  (Loomis). 

Treatment. — Repose  in- doors,  and  at  the  outset  a  full  dose  of 
quinine  and  morphia  (gr.  xv. — gr.  ss.)  exercises  a  favorable  influ- 
ence. Also  in  the  early  stages,  a  half  ounce  of  liquor  ammonii 
acetatis,  and  one  grain  of  pulvis  ipecac,  every  two  or  three  hours 
is  all  that  is  required.  The  bowels  should  be  kept  freely  open 
with  salines.  If  patients  are  restless,  Dover's  powders  may  be 
given  in  small  doses.  For  the  prostration  give  stimulants.  For 
the  local  distress  in  nose  and  throat,  inhale  the  vapor  of  hot 
water. 

Bartholow  gives  the  following: 

R     Extracti  ipecacuanha  fld 5ij- 

Tinct.  opii    deodoratte 5iv. 

Tinct.  aconiti  radicis 3j. — M. 

Sig. :     Six  to  ten  drops  every    two  hours.     For  the    violent  head 
symptoms  bromide  of  potassium  may  be  given. 

(Loomis  and    Bartholow). 


284  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

INGROWING  TOE=NAIL. 

This  is  a  troublesome  and  painful  affection.  It  occurs  most 
frequently  on  the  great  toe. 

Causes. — Tight  narrow-soled  shoes  and  boots.  The  pressure 
causes  the  nail  to  cut  its  way  into  the  tissues,  the  tissues  become 
hypertrophied  and  ulcerate,  and  granulations  spring  up  from  the 
side  of  the  nail  (Sayre). 

Treatment. — Remove  the  exciting  cause.  In  mild  cases, 
insert  a  small  piece  of  cotton  or  lint  under  the  nail.  After  the 
application  of  the  cotton,  the  granulations  should  be  brushed 
over  with  nitric  acid  or  nitrate  of  silver.  Another  plan  of  treat- 
ment is  to  cut  a  gutter  in  the  center  of  the  nail,  which  has  a 
tendency,  it  is  said,  to  elevate  the  corners.  Still  another  plan  is 
to  divide  the  nail  on  a  line  with  the  incurved  edge,  and  strip  it 
off,  together  with  the  matrix  (Sayre). 

PRESCRIPTIONS  FOR  INGROWING  TOE=NAIL. 

|&     Liquor  potassre 31J. 

Aqua? 5J  ■ — M. 

Sig. :  Apply  on  cotton  to  the  margin  of  the  nail  at  the  ulcerated 
surface  to  soften  the  nail.  — Bartholow. 

J£     Acidi  tannici §j. 

Aquse  destillatae .3vj. — M. 

Sig.:     Paint  over  parts  daily.  — Biall. 

Jfc     Plurabi  (pulv.)  acjtatis sj. 

Tinct.  opii oj- 

Aquas ad gviij. — M. 

Sig.:  Shake  well  and  apply  constantly  until  the  inflammation  is 
reduced  and  pain  alleviated.  Then  insert  a  pledget  of  cotton  under 
nail,  and  apply  following  : 

Jfc     Argenti  nitratis gr.  xxx. 

Aquae  destillatae §j. — M. 

Sig.:     Apply  two  or  three  times  daily  with  a  brush. — Davidson. 

INSOMNIA. 

Is  sleeplessness.  It  occurs  in  cerebral  congestion  aud  in- 
flammation. But  a  person  may  be  sleepless  from  excessive  pain, 
from  exhaustion,  from  grief,  from  mental  excitement  or  fatigue, 


insomnia.  285 

or  from  the  free  use  of  coffee  or  tea.  In  several  of  these  states, 
congestion  is  the  immediate  cause  of  the  wakefulness.  Insomnia 
attends  the  delirium  of  typhoid  fever,  but  is  most  marked  in 
delirium  tremens. 

Treatment. — When  wakefulness  is  due  to  a  condition  of  cere- 
bral anaemia,  a  full  dose  of  some  alcoholic  fluid,  whiskey  or 
brandy,  will  produce  sound  and  refreshing  sleep.  In  some 
persons  a  glass  of  ale  or  beer  answers  better.  Sulfonal  in  doses 
of  30  to  60  grains,  causes  sleep  that  is  physiological  in  character, 
but  pain  hinders  its  action.  Cases  of  sleeplessness,  due  to 
mental  over-work,  anxiety  or  physical  fatigue  are  entirely  re- 
lieved by  fifteen  to  twenty  grains  of  chloral.  The  bromide  of 
potassium  is  effective  in  the  same  cases.  Morphine  and  atropine 
is  the  best  sleep-producer  in  cases  of  pain,  in  some  kinds  of 
mania,  and  in  melancholia.  A  hop-pillow  has  induced  sleep. 
Galvanization  will  sometimes  cause  sleep.  A  tepid  or  warm  bath 
at  bedtime  will  often  produce  sleep  (Bartholow). 

PRESCRIPTIONS  FOR  INSOMNIA. 

R     Paraldehyde oiiss. 

Alcoholis  (90  per  cent.) Siss. 

Tinct.  vanillas 5ss. 

Aquas Sij. 

Syr.  simplicis ad oiv. — M. 

Sig. :     One  or  two  teaspoonfuls  every  hour.  — Yvon. 

R     Ext.  piscidias  erythrin  fid 5j. 

Syr.  simplicis 5j. 

Aquas  auranti  flor oiv. — M. 

Sis.:     A  teaspoonful  to  a  tablespoonml  at  bedtime.  — Payne. 

R     Anti  pyrin 5,j  .-ij  • 

-Syr.  auranti  cort Sj- 

Aquas  cinnamomi ad Siij. — M. 

Sig.:     One  tablespooni'ul  every  hour  or  two  till  effective. 

— Williams. 

R     Amyl  hydratis gr.  xiv. 

Syr.  auranti  cort ,~>ss. 

Aquas 3J  • — M. 

Sig.:     Take  at  bedtime.  — Von  Mering. 


286  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Methylol Sj. 

Syr.  auranti  flor §iv. — M. 

Sig. :     One  teaspoonful  at  bedtime.  — Richardson. 

R     Potassii  bromidi 3iv. 

Chloral  hydratis 5ij. 

Syr.  pruni  virgin Sj. 

Aquas ad $iij . — M. 

Sig. :     A  dessertspoonful  in  a  glass  of  water  at  bedtime. 

INTERMITTENT  FEVER.     (See  Malarial  Fever). 

INTERTRIGO. 

Is  chafing  of  adjacent  parts.  It  is  a  form  of  erythema.  It 
occurs  at  parts  where  opposed  surfaces  of  skin  are  in  contact 
with  one  another,  as  between  the  hips,  at  the  flexures  of  the 
thighs,  in  the  arm -pits,  and  under  pendulous  mamma?,  the  inflam- 
mation being  favored  by  the  heat,  moisture,  and  friction  of  the 
parts.  It  is  especially  apt  to  occur  in  hot  weather,  in  the  case  of 
corpulent  persons,  and  in  infants.  The  affected  surface  has 
a  reddened  glazed  appearance  and  the  itching  is  often  intoler- 
able (Anderson). 

Treatment. — Violet  powder  is  used  to  prevent  intertrigo  in 
infants.  In  intertrigo  and  in  the  erythema  which  occurs  about 
the  genitals  of  infants,  dusting  the  affected  surface  with  bismuth 
soothes  the  pain  and  promotes  healing.  Tannin  in  j)owder,  or 
the  glycerites  of  tannin,  applied  to  the  affected  surface  is  very 
effective.     The  following  lotion  is  useful: 

R     Aluminus.. gr.  xx. 

Zinci  sulph gr.  x. 

Glycerinae 5j  • 

Aquas  rosse 5iv. — M. 

Sig.:     Apply  to  affected  surface.  — Bartholow. 

Camphor  is  a  useful  addition  to  dusting  powder  to  allay  the 
heat,  tingling  and  itching  of  eczema  and  intertrigo  (Ringer). 


INTESTINAL    OBSTRUCTION.  287 

PRESCRIPTIONS  FOR  INTERTRIGO. 

R     Pulveris  amyli ,?iv. 

Zinci  oxidi §j- 

Zinci  carbonatis. §ss.— M. 

Sig.:     Use  as  a  dusting  powder.  —Tilbury  Fox. 

R     Acidi  boracici 3iss. 

Vaselim 3j— M. 

Sig.:  Apply  locally  after  washing  and  drying  the  parts.— Waring. 

R     Bismuthi  subcarbonatis §ij. 

Sig.:     Use  as  a  dusting  powder.  — Bartholow. 

R     Ammonii  sulphoichthyolati gr.  iij. 

Cumarini gr.  xij. 

Unguenti  petrolei 3v. — M. 

Sig.:     Apply  with  the  finger  after  bathing  and  drying  the  child. 

— Lor  ens. 

R     Linimenti  aquae  calcis §vi. 

Sig.:     Use  locally.  —Tilbury  Fox. 

INTESTINAL  CATARRH.     (See  Enteritis.) 

ITCH.     (See  Scabies.) 

INTUSSUSCEPTION.     (See  Intestinal  Obstruction.) 

INTESTINAL  OBSTRUCTION. 

Is  a  mechanical  impediment  to  the  movement  of  the  bowels. 
It  may  be  complete  or  incomplete. 

Inquire  of  the  patient:  1.  If  lie  has  ever  had  a  previous 
peritonitis,  or  intestinal  troubles,  as  colic,  pains,  etc.  2.  The 
manner  in  which  the  attack  appeared,  whether  suddenly  or  grad- 
ually. 3.  If  there  is  any  exciting  cause  present,  as  a  hernia, 
swallowing  a  foreign  body,  etc.  The  obstruction  may  come  on 
while  the  patient  is  asleep  or  in  perfect  health,  or  after  an  indi- 
gestible meal,  or  while  straining  at  stool  with  a  distended  blad- 
der. As  certain  as  obstruction  occurs  in  the  small  intestine, 
acute  symptoms  are  developed,  vomiting  of  bile  comes  on  sud- 
denly, and  tympanites  is  absent  generally.  Collapse  is  profound. 
The  shape  of  the  abdomen  is  similar  to  the  pregnant.  If  the 
obstruction  occurs  in  the  large  intestine,  chronic  symptoms  are 


288  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

developed,  and  there  is  fixed  pain,  and  tympanites  with  disten- 
sion of  the  colon.  Collapse  is  less  profound.  Great  distension 
of  the  abdomen  develops  rapidly.     It  occurs  late  in  life. 

Causes. — I.  Strangulation  inside  of  the  cavity. 

II — Changes  within  the  lumen  of  the  gut. 

III. — Changes  without  tie  lumen  of  the  gut. 

The  causes  of  strangulation  of  the  bowels  are:  1.  Peri- 
toneal adhesions  by  bands,  over  loops,  through  apertures,  or  at- 
tachment to  the  viscera,  (the  result  of  acute  peritonitis).  2. 
False  diverticulum.  3.  Hernia.  4.  Volvulus.  5.  Intussuscep- 
tion.    6.     Kinking  of  the  gut. 

The  causes  of  changes  without  the  lumen  of  the  gut  are:  1. 
Compression  from  anything  outside  of  the  gut.  2.  Contraction 
of  the  mesentery  following  inflammation  of  the  same.  3.  Chronic 
peritonitis.     4.  Retroflexed  uterus  especially  during  pregnancy. 

The  causes  of  changes  within  the  lumen  of  the  gut  are:  1 
Stenosis  or  stricture  from  malignant  growths  or  ulcerations.  2. 
Gall-stones.  3.  Foreign  bodies.  4.  Enteroliths.  5.  Faecal  im- 
paction. 

False  Diverticulum. — May  be  the  result  of  the  viteline  duct 
remaining  pervious  in  the  fxetus,  or  of  a  small  piece  projecting 
from  the  ileum  like  the  finger  of  a  glove,  from  one  to  three  feet 
above  the  ileo-caecal  valve,  or  it  may  be  formed  from  the  mucous 
coat,  by  a  rupture  of  the  muscular  coat,  making  a  hernia  of  the 
mucous  coat. 

Hernia. — As  a  cause  of  intestinal  obstruction,  is  formed  by 
weakening  of  the  walls  of  the  intestine,  and  is  found  on  the 
mesentric  borders  of  the  gut.  The  cause  may  also  be  faecal 
matter.  The  pouch  comes  from  the  ileum  three  to  four  feet 
above  the  ileo-caecal  valve. 

Volvulus. — Is  the  twisting  of  the  gut  upon  its  own  axis,  or 
upon  the  mesenteric  axis.  It  occurs  most  frequently  in  the  ileum 
colon,  caecum  and  sigmoid  flexure.  Thirty-three  of  1000  cases 
are  due  to  volvulus.  Russians  suffer  more  than  other  nationali- 
ties, because  they  have  eight  feet  more  of  ileum,  and  eat  a  more 
vegetable  diet.  In  the  ileum  it  goes  from  left  to  right  and  once 
upon  the  mesenteric  axis.  It  occurs  at  about  twenty  years  of  age. 
This  variety  comes  on  very  suddenly,  and  with    no    assignable 


INTESTINAL    OBSTRUCTION.  289 

cause.  Give  an  enema  early,  and  reach,  and  distend  the  colon 
and  percuss  it,  then  you  will  know  whether  the  obstruction  is 
above  the  ileo-csecal  valve  or  below  it.  In  the  sigmoid  flexure, 
it  is  very  common  in  chronic  constipation  as  the  bowels  become 
filled  by  faecal  matter  and  gas,  and  fall  over  each  other.  Gener- 
ally occurs  after  middle  life,  after  40  years  of  age.  Tenesmus  is 
very  distressing  in  the  bowels.  Volvulus  may  come  from  trau- 
matism, as  a  stabbing  into  the  abdomen;  also,  from  active  peris- 
talsis when  the  gut  twists  upon  itself. 

Intussusception. — Is  where  one  part  of  the  bowel  is  thrust 
into  another  part.  It  is,  also,  called  invagination.  One-third  of 
all  cases  of  intestinal  obstruction  is  of  this  kind.  Twenty-five 
per  cent,  occur  before  the  first  year,  and  fifty  per  cent,  before  the 
tenth  year.  It  most  frequently  occurs  in  the  ileum,  colon,  ileo- 
cecal valve,  and  rectum.  It  is  caused  by  irregular  contraction 
of  the  bowels,  and  has  been  produced  on  animals  by  electricity. 

If  there  be  an  intermittent  pain,  it  denotes  that  the  obstruc- 
tion is  incomplete.  If  there  be  a  continued  pain  it  shows  that 
the  obstruction  is  complete.  Bloody  stools  are  seen  in  eighty 
per  cent,  of  the  cases. 

Stenosis  or  Stricture  from  Malignant  Growths  or  Ulcera- 
tions— is  due  to  peptic,  typhoid,  tubercular,  catarrhal,  syphilitic 
and  dysenteric  ulcers.  Peptic  ulcer  is  found  in  the  duodenum 
and  is  said  to  be  due  to  the  action  of  the  gastric  juice.  It  occurs 
in  middle  life.  Typhoid  ulcers  are  found  in  the  long  axis  of  the 
gut  of  the  ileum.  The  tubercular  ulcers  are  found  in  the  lower 
ileum,  and  originate  in  the  lymphatic  glands,  and  lie  in  the 
transverse  direction  of  the  gut.  Catarrhal  ulcers  are  found  in 
the  colon,  and  are  produced  by  chronic  constipation.  They  are 
in  large  numbers  and  produce  gangrene  of  the  mucous  membrane. 
Syphilitic  ulcers  are  usually  found  in  the  rectum,  in  the  submu- 
cous tissue,  and  are  broken  down  gummata.  Dysenteric  ulcers 
are  found  in  the  rectum  and  sigmoid  flexures.  Stenosis  from  ma- 
lignant growths  are  usually  from  carcinoma  (epithelioma)  and 
may  be  primary  or  secondary.  It  usually  forms  an  annular 
stricture  and  there  comes  just  above  the  stricture  dilatation  and 
hypertrophy  of  the  bowel. 


290  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Gall  Stones — Which  produce  obstruction  are  usually  small 
but  become  enlarged  when  passing  through  the  intestine  by  co- 
hering together.  The  symptoms  are  not  so  sudden  or  great,  as 
by  bands  or  loops.  There  are  previous  hepatic  colic,  and  the 
presence  of  jaundice  usually.  It  is  more  frequent  in  women  then 
in  men. 

Foreign  Bodies — Are  any  bodies  not  acted  upon  by  the  gas- 
tric juice.  These  may  be  swallowed  for  suicide  or  by  the  insane 
or  accidentally. 

Enteroliths — Are  intestinal  calculi.  They  are  composed  of 
phosphorus,  calcium,  magnesium  carbonate,  with  cholesterine, 
and  are  formed  about  a  necleus.  This  form  of  trouble  is  fre- 
quent in  Scotland  where  the  peasants  live  on  coarse  oatmeal. 

F cecal  Impaction — Is  due  to  the  faeces  which  become  hard 
and  tend  to  remain  in  the  bowel.  The  bowels  move  very  seldom 
once  in  three  or  four  weeks,  and  thus  it  is  a  cause  of  local  ob- 
struction. In  all  cases  a  tumor  can  be  felt  under  the  integument 
and  the  feeling  is  like  that  of  putty.  A  bucketful  of  f secal  mat- 
ter has  been  removed.  It  may  lead  to  peritonitis.  It  is  more  com- 
mon in  women  than  in  men.  It  may  be  relieved  by  mechanical 
means,  but  the  patient  may  die  from  exhaustion. 

Compression  from  anything  outside  of  the  Gut — May  pro- 
duce obstruction.  It  may  be  from  sarcoma  of  pelvis.  It  may  be 
from  tumor  of  the  kidneys  or  abscess  connected  with  Pott's  dis- 
ease, or  hydatid  cysts  of  the  liver,  displaced  spleen,  etc.  Con- 
traction and  inflammation  of  the  gut  may  produce  it.  Chronic 
peritonitis  and  tubercular  peritonitis  with  adhesions,  retroflexed 
uterus,  and  enlarged  tubes  due  to  pregnancy  may  cause  intestinal 
obstruction  (Dennis). 

Symptoms. — 1.  Pain  which  is  very  severe  and  is  present 
early,  is  usually  referred  to  the  umbilicus,  because  near  this  are 
the  great  solar  and  mesenteric  plexuses.  The  situation  of  the 
pain  is  no  criterion  to  the  situation  of  the  obstruction  in  the  early 
stages.  Note  that  continuous  pain  denotes  complete  obstruction 
and  paroxysmal  pain  denotes  incomplete  obstruction,  and  if  the 
pain  suddenly  ceases  it  denotes  gangrene.  There  is  a  localized 
peritonitis. 


INTESTINAL    OBSTRUCTION.  291 

2.  Vomiting  comes  on  early  when  the  obstruction  is  in  the 
small  intestine.  The  contents  of  the  stomach  are  first  ejected, 
then  the  biliary  secretions,  and  last  stercoraceous  material  about 
the  fifth  day.  Vomiting  usually  occurs  just  after  the  pain,  and 
when  suddenly  stopping,  denotes  gangrene. 

3.  Constipation  is  present  and  continuous.  Bowels  do  not 
move  above  the  constriction.  Note  the  presence  of  blood  in  the 
stools.  If  there  is  blood,  it  is  likely  to  be  intussusception.  The 
blood  may  come  from  hemorrhoids. 

4.  Abdominal  Tenderness  is  important,  but  is  absent  at  the 
beginning  of  the  attack .  It  supervenes  quickly,  and  appears 
about  the  third  day,  and  is  diagnostic  as  a  symptom  because  it 
points  to  local  peritonitis,  and  if  it  is  diffused  it  denotes  general 
peritonitis. 

5.  There  is  a  tumor  or  swelling  in  the  abdomen. 

6.  The  pulse  is  thready  and  rapid,  110  to  140  per  minute 
and  small. 

7.  Temperature  is  subnormal,  as  a  rule;  if  peritonitis  sets 
in  it  may  rise  to  100°  F.,  and  if  perforation  takes  place,  it  falls 
below  normal  to  97°  F. 

8.  Respirations  are  more  frequent,  suj;)erficial  and  thoracic. 

9.  Anuria. — Urine  is  scanty  and  contains  albumen  and 
indican. 

10.  Physiognomy  has  a  haggard  expression  from  mental 
suffering,  face  is  drawn,  eyes  are  sunken,  and  the  intellect  is 
good  to  the  end.     Collapse  finally  comes  on. 

Caution. — Do  not  give  cathartics,  because  they  will  intensify 
the  pain,  produce  more  vomiting,  increase  shock,  produce  stran- 
gulation, causing  perforation  and  peritonitis.  It  may  convert 
a  chronic  into  an  acute,  and  may  induce  intussusception.  Metalic 
mercury  is  not  much  used  and  should  not  be  till  the  last. 

Symptoms  of  Perforation  are  : 

1.  Emphysema  of  the  abdomen,  which  is  sometimes  due  to  a 
gunshot  wound  or  some  oj^ening. 

2.  Shock,  the  patient  is  in  collapse. 

3.  Condition  of  the  Pulse  is  diagnostic,  on  account  of 
heart  disturbance  due  to  perforation.  It  is  rapid,  thready  and 
feeble. 


292  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

4.  Tympanitic  resonance  over  the  liver.  There  are  two 
conditions  of  tympanites  without  perforation,  namely  :  1.  When 
the  colon  is  pushed  up  and  is  adherent  to  the  walls;  and  2.  Em- 
physema of  the  lower  lobe  of  the  lung.  The  respirations  are 
rapid  and  thoracic  in  character. 

5.  Sudden  tympanites  at  the  seat  of  perforation. 

6.  Subnormal  temperature. 

7.  Vomiting. 

8.  Sometimes  bloody  stools,  especially  in  traumatism. 

9.  Retention  of  urine. 

10.     Acute  peritonitis  and  anxious  physiognomy  (Dennis). 

Treatment. — Give  morphine  hypodermically.  Small  doses 
stimulate  and  large  ones  paralyze,  therefore  large  doses  and  not 
small  ones  are  indicated.  It  relieves  intense  pain,  influences 
shock  and  relaxes  the  abdominal  walls.  It  increases  the  secre- 
tion of  urine,  affects  the  pulse,  respiration,  temperature,  and 
vomiting.  It  arrests  peristalsis.  Caution. — If  it  is  continued 
too  long,  retention  of  the  bowels  is  produced,  which  is  not  good. 

Nourishment. — We  cannot  nourish  by  way  of  the  stomach,, 
for  it  is  filled  with  regurgitant  fluid,  and  the  intestines  are  filled 
with  gas.  Nourish  by  the  rectum  and  give  enema  of  milk  (4 
oz.).  We  may  use  hypodermics  of  brandy.  Let  the  patient 
have  ice  in  his  mouth  to  quench  his  thirst.  It  will  help  to 
control  vomiting  and  keep  the  tongue  moist. 

Local  Applications.— Warm  ones  will  relax  the  abdominal 
muscles.  Turpentine  stupes  over  the  abdomen  is  good.  Hot 
flannels  and  poultices  are  good.  Place  a  pillow  under  the  popli- 
teal space. 

Enemata. — Copious  ones  in  intestinal  obstruction  are  good. 
They  must  be  introduced  slowly.  If  a  fountain  syringe  be  used, 
it  must  be  lower  than  six  or  seven  feet  for  children,  and  lower 
than  15  to  18  feet  for  adults.  Warm  water  with  soap-suds  and 
olive  oil  is  good.  If  glycerine  is  added  it  will  be  better.  Do 
not  use  the  injection  late  in  the  disease,  for  gangrene  will  be 
produced. 

Aspirations,  or  Paracentesis. — Should  we  aspirate  or  not  ?  It 
is  dangerous  and  must  not  be  done  only  in  extreme  cases,  and 


INTESTINAL    OBSTRUCTION.  293 

then    must    not    be    done   without    consultation   of    some    other 
surgeon. 

Operation. — Laparotomy:  Results  are  good  when  the  oper- 
ation is  done  early,  and  before  the  patient  is  exhausted,  and 
before  peritonitis  sets  in.  Do  not  operate  if  there  is  suppuration 
with  general  peritonitis,  or  if  the  cause  is  some  malignant  dis- 
ease. First,  have  the  parts  thoroughly  cleansed  with  a  warm 
solution  of  bichloride.  In  the  cavity  do  not  use  a  solution 
stronger  than  1  to  10,000,  and  never  use  the  same  sponge  twice. 
Always  empty  the  bladder  before  the  operation.  Make  the  in- 
cision in  the  median  line,  and  the  higher  we  go  above  the  umbil- 
icus the  worse  it  wrill  be,  for  the  gut  cannot  be  easily  returned. 
If  the  ileo-caBcal  valve  is  collapsed  the  obstruction  is  in  the  small 
intestine  and  not  in  the  large.  If  by  bands  strangulation  is 
caused,  cut  the  bands  between  the  ligatures.  If  by  a  slit,  through 
which  the  gut  has  gone,  sew  up  the  slit.  If  by  a  false  diverticu- 
lum, cut  it  off,  and  bring  the  edges  of  peritoneum  together,  and 
let  an  adhesion  form.  If  by  hernia,  cut  out  the  damaged  gut 
and  make  an  artificial  anus.  If  by  volvulus,  and  it  involves  the 
ileum,  simply  untwist  it,  but  if  the  sigmoid  flexure  is  involved, 
do  a  left  lumbar  colotomy.  If  by  intussusception,  which  occurs 
in  childhood  largely,  'and  if  it  affects  the  small  intestine,  simply 
draw  it  out;  if  that  cannot  be  done,  make  an  artificial  anus  just 
above  the  obstruction.  Do  the  operation  early.  If  the  obstruction 
is  caused  by  stenosis  from  ulceration  or  malignant  disease,  do  a 
laparotomy  and  remove  the  disease  and  make  an  artificial  anus,, 
then  later  on  re-establish  the  contiguity  of  the  gut.  If  by  gall- 
stones, open  the  gut  and  remove  them  or  any  other  foreign 
bodies.  If  by  faecal  impaction,  it  may  be  removed  by  manipula- 
tion. If  by  growth  or  neoplasm,  remove  the  growth  if  possible, 
and  if  not,  open  the  gut.  We  have  sarcoma  of  the  pelvis,  tumors 
of  the  kidneys,  mesentery,  omentum,  and  abscess  of  Pott's  dis- 
ease. In  chronic  peritonitis,  wash  out  the  cavity  with  bichloride 
solution  1  to  10,000.  It  is  successful  where  there  is  tuberculous 
disease,  but  not  in  carcinoma.  In  contraction  of  the  mesentery, 
do  a  laparotomy.  If  the  obstruction  is  caused  by  retro-flexed 
uterus,  bring  it  forward. 


294  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Laparotomy  for  Acute  Intestinal  Obstruction. — The  results  of 
laparotomy  are  encouraging.  Before  the  clays  of  aseptic  and 
antiseptic  surgery,  the  death  rate  was  75  per  cent.;  after  that 
time  58  per  cent.  The  percentage  of  deaths  is  due  to  two  causes: 
1.  Shock.  2.  Sepsis.  Shock  may  be  diminished  by  an  early 
and  rapid  operation.  Ser^sis  may  be  diminished  by  adhering 
strictly  to  aseptic  and  antiseptic  surgery.  If  there  is  suppuration 
do  not  operate.  Duration  of  life  in  acute  obstruction  of  the  in- 
testines is  six  days;  so  operate  early.  If  laparotomy  is  done  and 
the  cause  removed,  the  per  cent,  of  deaths  is  56.  If  the  cause  is 
not  removed  the  percentage  of  death  is  66.  If  the  gut  is  gan- 
grenous, and  is  opened,  and  afterward  sutured,  the  percentage 
of  death  is  86  (Dennis). 

PRESCRIPTIONS  FOR  INTUSSUSCEPTION. 

R     Fellis  bovini gr.  xx. 

Aqua?  ferventis Oij . — M. 

Sig. :     Inject  slowly  into  the  bowel   until  it  is  full}T  distended. 
(Knee-chest  position  is  best.)  — Hawkins. 

R     Lobelia?   .5ss. 

Aqua?  bullientis Oj. — M. 

Sig.:     Inject  one-fourth,  or  one-half,  and  repeat  if  necessary. 

— Bartholow. 

R     Extracti  belladonna? gr.  iv. 

Aqua?  ferventis Oj. — M. 

Sig.:     Inject  into  the  rectum.  — Waring. 

R     Sodii  bicarbonatis  3j. 

Aqua? 5  vj . — M. 

Sig.:     Inject  into  the  rectum  and  follow  at  once  with, 

R     Acidi  tartarici  pulv  gr.  xxxv. 

Aqua?  5 iv. — M. 

Sig.:     Inject  into  the  bowel  at  once  after  the  preceeding. 

— Bartholow. 

IRITIS. 

Is  an  inflammation  of  the  iris. 

Causes. — Are  local  and  constitutional.  It  may  come  from 
functional  strain,  from  injury,  from  operations,  from  penetration 
of  foreign  bodies  or  by  extension  of  inflammation  from    adjacent 


iritis.  295 

structures.  The  constitutional  causes  are  syphilis,  rheumatism 
and  gout.  About  fifty  per  cent  of  all  cases  is  caused  by  syphilis. 
Rheumatism  and  gout  cause  obstinate,  painful  and  recurrent  at- 
tacks of  iritis.  In  syphilitic  iritis,  a  plastic  or  gummy  exudation 
is  thrown  out.  Gonorrhoea  occasionally  causes  iritis.  Other  causes 
are  malaria,  variola,  scrofula,  and  tuberculosis  (Noyes). 

Symptoms. — Are  objective  and  subjective.  The  former  are 
change  of  color  of  the  membrane,  abnormal  behavior  of  the  pupil 
and  injected  blood  vessels.  A  blue  iris  will  change  to  a  dull 
gray,  a  hazel  to  a  dirty  brown.  The  aqueous  humor  is  turbid, 
and  the  pupil  is  smoky  instead  of  a  clear  jet  black.  The  pupil 
will  be  small  and  will  not  respond  to  light.  Adhesions  will  be- 
come apparent  upon  dropping  a  solution  of  atropia  into  the  eye. 
In  severe  cases,  the  whole  front  of  the  eye  will  be  intensely  red. 
The  lids  will  be  imperfectly  opened.  The  subjective  symptoms 
will  be,  impairment  of  sight,  intolerance  of  light,  and  pain.  The 
pain  is  first  situated  in  the  globe,  and  is  a  consjncuous  feature 
from  the  outset,  is  most  severe  toward  night,  or  early  morning. 
Iritis  may  attack  one  eye  or  both.  It  generally  lasts  two  to  six 
weeks,  if  neglected  it  may  continue  for  months,  with  entire  loss 
of  sight. 

Sequelw  of  Iritis  are:  1.  Adhesions  of  the  iris  to  the 
capsule  of  the  lens.  2.  The  exudation  may  become  organized 
and  fill  the  whole  pupil,  and  thus  resemble  cataract.  3.  The 
capsule  of  the  lens  may  become  thickened  (Noyes). 

Prognosis. — In  simple  cases,  vision  will  be  perfectly  restored, 
but  if  adhesions  take  place,  sight  will  be  impaired  (Noyes). 

Treatment. — Avoid  use  of  eyes,  and  all  sources  of  irritation. 
The  patient  must  be  kept  in  a  dark  room.  The  essential  and 
master  remedy  in  iritis  is  a  solution  of  atropine;  it  is  the  begin- 
ning, middle  and  end  treatment.  A  solution  of  four  grains 
to  the  ounce  must  be  used  and  dropped  in  four  to  six  times  daily. 
If  poisonous  symptoms  appear  from  the  use  of  the  atropine  it 
must  be  stoj3ped,  and  the  ]3roper  treatment  instituted.  Appli- 
cations of  warm  water  to  the  eye  are  useful.  For  the  nocturnal 
pain,  hot  fomentations  are  to  be  used,  and  morphia  administered. 
Constitutional  treatment  will  be  necessary  in  cases  of  syphilitic, 
rheumatic,  or  gouty  iritis.     Gonorrhoea]  iritis  demands   urethral 


296  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

treatment.  For  severe  serous  iritis  with  deep  anterior  chamber 
and  much  pain,  paracentesis  will  be  effectual.  When  mydriatics 
fail  and  the  pupil  is  much  bound  down,  iridectomy  is  the  remedy 
(Noyes). 

PRESCRIPTIONS  FOR  IRITIS. 

{&     Atropine  sulphatis . ...gr.  iv. 

Aquae  destillatse 3j • — M. 

Sig. :     A  drop  or  two  in  the  eye  three  times  daily.  Used  with  hot 
water,  bathing  for  fifteen  minutes  every  hour  till  pain  is  relieved. 

—Chilton. 

R     Hydrargyri  chlor.  corros gr.  j. 

Potassii  iodidi 3j . 

Tinct.   calumbse .$ij. 

Aqua?  destillatse ad  3yj. — M. 

Sig.:     A   dessertspoonful  in  water  three  times  daily.     — Lawson. 

R     Seopolinse gr.  j. 

Aqua?  destillatse 3J . — M. 

Sig. :     Two  drops  into  the  eye  three  times  daily.  — Dunn. 

R     Emplastri  cantharidis  1  in.  by  1  in. 

Sig.:     Apply  behind  the  ear,  and  poultice  when  blistered. 

— Hartshorne. 
R     Duboisise  sulphatis gr.  j. 

Aquae  destillatse 3j • — M. 

Sig. :     One  drop  into  the  eye  twice  daily.  — Tweedy. 

ICTERUS.     (See  Jaundice). 

INSOLATION.     (  See  Heatstroke  ) . 

IODISM. 

If  iodine  or  the  iodides  are  administered  in  too  large  doses, 
or  to  persons  of  irritable  stomach,  and  for  too  long  a  time,  they 
will  produce  gastro- enteric  symptoms,  headache,  giddiness, 
marasmus,  sometimes  discoloration  of  the  skin,  occasionally  sali- 
vation, and  frequently  a  wasting  of  the  mammae  and  testicles. 
This  train  of  symptoms  is  called  iodism. 

Treatment, — Withdraw  the  drug  and  give  arsenic.  Atropine 
is  quite  effective  as  a  remedy  for  iodism  (Bartholow). 


IRRITABILITY JAUNDICE.  297 

IRRITABILITY. 

Cause. — All  those  practices  and  habits  which  cause  nervous 
strain,  and  result  in  nervous  exhaustion,  may  produce  irritability. 

Treatment. — Give  five  grains  of  chloral  two  or  three  times  a 
day  in  irritability  with  nervousness  and  restlessness.  A  sitzbath 
with  the  water  between  60°  and  80°  greatly  relieves  fatigue,  and 
soothes  an  irritable  restless  state  of  the  nervous  system. 

ITCHING.     (See  Pruritis). 

JAUNDICE. 

Called  also  icterus,  is  a  yellow  discoloration  of  the  skin  due 
to  the  presence  of  bile  or  blood  pigment  (Loomis).  Jaundice  is 
a  symptom  common  to  many  affections  of  the  liver. 

Causes. — /.  Of  Hepatogenous  Jaundice. — Duodenal  ca- 
tarrh, biliary  calculi,  inspissated  bile  and  mucus,  hydatid 
vesicles,  foreign  bodies  from  the  intestinal  canal,  such  as  stones  of 
fruit  and  round  worms,  congenital  plugging  of  the  duct  and  cancer 
of  the  ducts  are  causes  within  the  duct.  The  causes  which  ob- 
struct the  duct  by  external  pressure  are  :  Tumors  of  the  pyloric 
extremity  of  the  stomach,  of  the  head  of  the  pancreas  and  of  the 
kidney;  pressure  from  a  pregnant  uterus,  from  ovarian  and 
fibroid  tumors,  from  omental  tumors,  from  large  impaction  of 
f  aeces,  from  enlarged  lymphatic  glands  in  the  transverse  fissure, 
from  waxy  cancerous  or  tubercular  change,  from  abdominal 
aneurism  and  from  hypertrophic  cirrhosis  of  the  liver. 

II  Causes  of  Hematogenous  Jaundice  are:  Yellow, 
typhus,  typhoid  and  malarial  fevers  (Loomis). 

Symptoms. — Jaundice  first  appears  in  the  conjunctiva,  then 
the  skin  of  the  face  appears  sallow  or  fawn -col  or.  The  urine 
early  undergoes  a  change  and  becomes  intensely  colored  with 
bile-pigment,  which  it  imparts  to  linen  and  white  paper  dipped 
into  it.  The  best  test  for  bile  in  the  urine  is  the  nitric  acid  test. 
Pour  into  a  test  tube  an  inch  of  nitric  acid,  and  drop  the  mine 
slowly  on  top  of  the  acid.  If  bile  be  present,  there  will  be  a  red 
line  next  the  acid  and  green  uppermost  with  violet  and  blue 
between.     The   stools  in  jaundice  are   grayish  or  slate-colored, 


298  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

sometimes  quite  white.  Jaundice  is  usually  unaccompanied 
by  pain.  Headache  is  a  common  symptom.  There  is  drowsi- 
ness, hebetude  of  mind  and  despondency.  In  some  cases  there 
are  nausea,  a  persistent  harassing  cough,  and  muscular  soreness. 
The  temperature  in  jaundice  is  usually  below  the  normal.  In 
many  cases  the  pulse  is  slow;  more  or  less  itching  of  the  skin; 
sometimes  an  intolerable  itching  is  observed  in  many  cases.  The 
taste  is  bitter.     The  vision  may  be  yellow  (Bartholow). 

Differential  Diagnosis. — The  yellow  staining  is  slight  in  hem- 
atogenous jaundice,  but  it  is  more  intense  in  hepatogenous. 
There  is  great  itchiug  of  the  surface  in  hepatogenous  jaundice 
which  is  absent  in  the  hematogenous  variety.  The  faeces  are 
dark  in  hematogenous  jaundice  and  white  or  clay- colored  in 
hepatogenous  (Loomis). 

Determination  of  the  Cause. — If  the  jaundice  comes  on  in 
the  course  of  a  gastro- duodenal  catarrh,  it  is  probably  a  case  of 
simple  catarrhal  jaundice.  If  it  occurs  in  the  course  of  malarial 
fever,  it  is  probably  due  to  malaria.  If  the  jaundice  is  preceded 
by  sudden  violent  pain  in  the  right  hypochondrium,  it  is  due  to 
the  passage  of  gall-stones.  If  the  jaundice  be  persistent — lasting 
many  months — and  intense,  and  follow  an  attack  of  pain  which 
has  not  been  repeated  since,  it  is  probably  due  to  a  permanent 
occlusion  by  a  gall-stone.  If  the  jaundice  be  intense,  persistent 
and  painless  with  enlarged  liver,  it  may  signify  obstruction  by 
hydatids.  A  faint  jaundice  lasting  many  months,  with  ascites 
and  enlargement  of  the  superficial  veins  of  the  abdomen,  is  pro- 
duced by  sclerosis  or  cirrhosis  or  nutmeg  liver.  Jaundice  with 
persistent  pain  or  soreness  in  the  right  hypochondrium  indicates 
cancer  (Bartholow). 

Treatment. — Laxatives  and  diuretics  are  useful.  Grain  doses 
of  calomel  given  at  night  is  the  best  laxative  in  these  cases. 
Saline  laxatives  which  have  a  diuretic  action  are  very  useful. 
The  compound  jalap  powder  is  efficient.  In  malarial  jaundice, 
ten  to  thirty  grains  each  day  of  quinine  is  useful. 


JAUNDICE — KERATITIS.  299 

RRESCRIPTIONS  FOR  JAUNDICE.     (Catarrhal.) 

R     Ammonii    chloridi 3ss. 

Ext.  taraxaci  fluidi giij. — M. 

'Sig.:     A  teaspoonful  three  times  daily.  — Bartholow. 

R     Ext.  hydrastis  fluidi 3j. 

Sig.:     Ten  drops  before  meals  for  some  weeks.  — Bartholow. 

R     Sodii    phosphatis  §ij. 

In  pulv.  no.  xvi.  div. 
Sig. :     A  powder  every  four  hours.  — Bartholow. 

R     Ammonii  iodidi 5j- 

Liq.  potassii  arsenitis gss. 

Tinct.  calumbse §ss. 

Aqua? Siss. — M. 

Sig.:     A  teaspoonful  before  meals.  — Bartholow. 

KERATITIS.     (Phlyctenular). 

Is  an  inflammation  of  the  cornea.  It  is  characterized  by 
one  or  more  slight  elevations  of  a  grayish -white  or  yellow  color, 
which  are  about  the  size  of  a  pin  head.  Sometimes  they  are 
visicles  and  sometimes  semi -solids,  and  soon  their  summit  is 
eroded,  leaving  a  little  ulcer  (Noyes). 

Symptoms. — Are  subjective  and  objective.  There  will  be 
hyperemia,  severe  pain,  photophobia  and  lachrymation.  It  is 
especially  a  disease  of  children,  and  attacks  the  ill -fed  or  over- 
fed, the  weakly  and  the  dirty.  There  is  usually  eczema  of  the 
head  or  face.  In  bad  cases  the  cornea  may  be  perforated 
(Noyes). 

Causes. — Are  scrofula,  gout,  syphilis,  malaria,  eczema, 
herpes,  struma  and  exanthematous  diseases. 

Treatment. — Must  be  both  local  and  constitutional.  If  there 
be  only  one  or  two  eruptions,  and  they  recent  and  situated  on  the 
cornea,  they  may  be  scraped  out  clean  by  a  sharp  spud.  Then  tie 
up  the  eye,  and  wash  it  out  once  in  three  hours  with  a  two  per 
cent  solution  of  boric  acid.  Instead  of  the  scraping,  the  ointment 
of  yellow  oxide  of  mercury,  gr.  ij.  to  dr.  j.  maybe  rubbed  well  into 
the  eye  once  daily.  If  there  is  an  iritis  along  with  the  keratitis, 
a  solution  of  atropine  may  be  dropped  into  the  eye  thrice  daily. 
The  chief  remedy  against  photophobia  is  cocaine   which  may  be 


300  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

used  several  times  daily.  Cold  water  and  boric  acid  will  be 
grateful.  The  constitutional  and  hygienic  measures  are  never  to 
be  neglected.  Cleanliness,  pure  air,  exercise  and  a  suitable  diet 
will  be  needed.  Mild  purgatives  as  rhubarb  and  soda  are  some- 
times useful.  Cod-liver  oil  and  the  syrup  of  the  iodide  of  iron, 
are  standard  remedies  (Noyes). 

PRESCRIPTIONS  FOR  KERATITIS. 

{&     Atrophia?  sulphatis gr.  ij. 

Aquae  destillatae §j . — M. 

Sig. :     One  or  two  drops  into  the  eye  three  times  daily. 

— Bartholow. 

Jfc     Hydrarg  chloridi  corrosive gr.  j. 

Aquae  destillatae §iv. — M. 

Sig.:     Apply  as  a  bath  to  the  eye  by  means  of  a   reservoir  eye- 
cup.  — Grandmont. 

KIDNEY=DISEASES,     (See  Albuminuria,  Bright's  Disease  and 

Uraemia . ) 

KINQS'=EVIL.     (See  Scrofula.) 

KNEE=JERK. 

In  most,  healthy  individuals  a  vigorous  contraction  of  the 
quadriceps  extensor  muscle  is  produced  by  striking  quickly  with 
the  ulnar  side  of  the  hand,  the  ligamentum  patellae  when  the  leg 
is  flexed  and  the  muscles  are  relaxed.  This  contraction  is  called 
the  knee-jerk,  or  patellar  reflex,  and  may  be  increased,  dimin- 
ished or  abolished  in  certain  diseases  of  the  spinal  cord.  The 
centre  for  the  patellar  reflex  is  in  the  gray  matter  of  the  lumbar 
portion  of  the  spinal  cord.  Disease  of  the  gray  matter  in  this 
situation,  and  of  the  posterior  columns  of  the  lumbar  enlarge- 
ment, cause  the  patellar  reflex  to  disajDpear.  In  various  condi- 
tions causing  spastic  paralysis,  the  patellar  reflex  is  increased. 
In  posterior  spinal  sclerosis,  knee-jerk  is  absent;  it  is  also  absent 
in  disease  of  the  anterior  cornua.  Kuee-jerk  is  absent  in  many 
cases  of  diphtheria  from  the  very  first  day  of  the  illness  (Flint). 


LABOR.  301 

LABOR. 

Is  the  expulsion  of  the  foetus  from  the  uterus.  Normal  labor 
occurs  when  the  foetus  is  mature. 

The  Pains  of  Labor. — The  pains  of  labor  are  first  felt  over 
the  sacrum,  and  radiate  to  the  rectum,  bladder,  across  the  abdo- 
men and  down  the  thighs.  At  first  the  pains  are  dull,  but 
finally  reach  the  point  of  sujxreine  agony. 

Stages. — There  are  three  stages  of  actual  labor:  1.  The 
stage  of  dilatation  of  the  cervical  canal.  2.  The  stage  of  expul- 
sion of  the  child.     3.  The  stage  of  placental  delivery  (Lusk). 

Duration  of  Labor. — The  average  for  primiparse  is  seventeen 
hours,  for  multij)ar8e  twelve  hours.  For  the  after-pains  the  fol- 
lowing prescription  of  Witherstine  may  be  used: 

|fc     Morphiee  sulphatis . gr.  ij. 

Aquas  camphoras gij. — M. 

Sig. :     A  teaspoonful  every  three  hours. 

Leishman's  formula  may  be  used  for  precipitate  labor: 

J&     Morphia?  sulphatis gr.  j.-ij. 

Olei  theobromse 3ij. — M. 

Ft.  massa  et  in  suppositoria  no.  iv.  div. 
Sig.:     One  as  required. 

In  retained  placenta,  Atthill's  formula  is  useful: 

|fc     Tinct.  nucis  vomicae 3j. 

Ext.  ergotse  fluidi 3vi. 

El ixir  sim plicis ad gvi. — M. 

Sig. :     A  teaspoonful  in  a  wineglassful  of  water  every  three  hours. 

In  hour-glass  contraction  of  the  uterus,  Barnes  gives  three 
to  five  drops  of  amyl  nitrite  to  be  inhaled  from  a  handkerchief. 
In  protracted  labor  due  to  rigid  os,  Ringer  gives  the  fol- 
lowing: 

Jfc     Morphias  sulphatis gr.  ij. 

Aquse  destillatte oj • — M. 

Sig.:    Five  or  ten  minims  hypodermically,  repeated  as  necessary. 

In  protracted  labor  from  atony  of  the  uterus,  Leishman 
gives  the  following: 

Jfc     Extracti  ergotse  fluidi sj. 

Olei  gaultherise gtt.  iv. — M. 

Sig.:     A  teaspoonful  every  four  hours,  only  if  os  is  dilated,  and 
soft  parts  not  rigid. 


302  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

LARYNGISMUS  STRIDULUS. 

Called,  also,  spasm  of  the  glottis,  internal  convulsions,  child 
crowing,  etc.,  is  spasm  of  the  muscles  of  the  larynx. 

Violent  emotion,  especially  anger,  may  induce  a  temporary 
suspension  of  respiration  in  young  children.  In  the  midst  of 
their  crying,  they  suddenly  hold  their  breath,  but  it  is  not  fol- 
lowed by  a  stridulous  inspiration  as  it  is  in  true  spasm  of  the 
glottis  (Smith). 

Causes. — Laryngeal  spasm  is  most  frequently  met  with  in 
children,  when  indigestion,  teething  and  impressions  of  external 
cold  are  usually  assigned  as  causes.  Cerebral  irritation  is  given 
as  a  cause.  Scrofulous  and  cachectic  children  are  said  to  be  es- 
pecially  subject  to  spasms  of  the  glottis  (Loomis). 

Symptoms. — There  is  generally  previous  ill-health.  The  at- 
tacks are  more  frequent  and  severe  at  night,  in  or  after  the  first 
sleep,  than  in  the  day.  A  peculiar  crowing  sound  is  heard  now 
and  then  during  inspiration  especially  when  the  child  is  crying. 
In  severe  paroxysms  respiration  often  ceases  entirely  for  a  mo- 
ment. The  face  becomes  livid.  The  duration  of  the  paroxysm 
may  be  a  quarter,  a  half,  or  even  a  whole  minute.  The  parox- 
ysms may  occur  almost  daily  for  several  weeks  (J.  L.  Smith). 

Treatment. — During  a  paroxysm  it  is  customary  to  employ 
means  to  produce  a  strong  impression  on  the  surface,  as  slapping 
the  back  or  sprinkling  cold  water  on  the  face.  A  ready  and 
effective  mode  of  arresting  a  paroxysm  is  to  introduce  a  finger 
into  the  throat.  If  the  stomach  is  overloaded  an  emetic  is  indi- 
cated. Employ  a  hot  foot-bath,  and  warm  fomentations  to  the 
neck.  Laxatives  should  be  given.  From  ten  minims  to  one 
drachm  of  paregoric  often  arrests  the  paroxysm  (Bartholow  and 
Flint). 

PRESCRIPTIONS  FOR  LARYNGISMUS  STRIDULUS. 

R      Syrupi  ipecac  §ij. 

Sig. :     A  teaspoonful  every  ten  or  fifteen  minutes  until  free  emesis 
occurs.  — Bartholow. 

R     Chloroformi §j . 

Sig.:     A  few  drops  inhaled  from  a  handkerchief.      — Bartholow. 


LARYNGITIS.  303 

R     Tinct.  aconiti  rad 3ss. 

Sig. :     One  drop  in  a    teaspoonful  of  water  every  hour  for  three 
doses,  then  every  two  hours.  — Ringer. 

LARYNGITIS.     (Acute  and  Chronic.) 

Is  an  inflammation  of  the  mucous  membrane  of  the  larynx. 
It  may  occur  at  any  age.  There  is  an  acute  and  chronic  form  of 
the  disease. 

Causes. — Acute  catarrhal  laryngitis  is  caused  by  atmospher- 
ical changes,  by  exposure  to  wet  and  cold  and  by  chilling  of  the 
surface,  especially  of  the  neck  and  feet.  "Taking  cold"  is  a 
fruitful  cause  of  laryngitis.  Anything  that  irritates  the  laryn- 
geal mucous  membrane  may  produce  a  laryngitis  (Loomis). 

Symptoms. — Usually  at  first  there  is  soreness  of  the  throat, 
accompanied  by  a  sense  of  constriction,  or  a  tickling  sensation 
with  a  tendency  to  cough;  the  larynx  is  tender  on  pressure,  there 
is  difficulty  in  swallowing.  The  expectoration  is  at  first  tena- 
cious; later  it  may  become  thick,  purulent  and  abundant.  The 
voice  is  hoarse  or  is  reduced  to  a  whisper.  The  face  is  flushed, 
the  skin  hot  and  dry,  there  is  fever  and  a  frequent  pulse 
(Loomis). 

Treatment. — The  patient  should  be  confined  to  bed.  The 
air  of  the  apartment  should  be  kept  moist  by  vapor  of  water. 
Tincture  of  aconite  root — one  drop  for  a  child  and  two  drops  for 
an  adult  every  two  hours — is  highly  efficient.  If  there  be  much 
cough,  two  to  five  drops  of  the  deodorized  tincture  of  opium  and 
one  or  two  drops  of  the  fluid  extract  of  ipecac  may  be  given  to- 
gether. A  spray  of  a  solution  of  morphia  to  the  throat  is  an 
excellent  means  of  relieving  cough.  A  very  minute  quantity  of 
tartar  emetic,  with  paregoric  and  syrup  of  lactucarium  is  also  an 
efficient  combination.  A  hot  or  cold  pack  should  be  wrapped 
about  the  throat,  after  a  brief  application  of  mustard;  and  if  the 
case  is  just  beginning  the  feet  should  be  placed  in  a  hot  mustard 
foot-bath. 

Prophylaxis. — Those  who  have  frequent  attacks  should  wear 
flannels,  and  protect  the  feet  against  dampness.  Avoid  furs 
about  the  throat.  The  tendency  to  take  cold  may  be  obviated 
by  a  daily  morning  cold  sponge- bath.     The  access  of  an  impend- 


304  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ing  attack  may  be  prevented  by  a  full  dose  of  quinine  and  mor- 
phine (15  grs.-gr.  \  to  ^)  (Bartholow). 

Causes  of  Chronic  Laryngitis. — It  may  be  a  sequel  of  acute 
laryngitis.  It  may  occur  from  constant  use  of  the  voice  in  public 
speaking  or  singing.  It  constitutes  the  chief  morbid  condition 
in  what  is  termed  "clergyman's  sore  throat."  It  is  frequently 
secondary  to  chronic  nasal  catarrh.  It  most  frequently  occurs  as 
an  accompaniment  of  other  affections,  as  syphilis  and  pulmonary 
j3hthisis  (Loomis). 

Symptoms. — Of  chronic  catarrhal  laryngitis  are  local.  In 
some  the  voice  is  hoarse  and  husky;  in  other  cases,  the  patient  is 
only  able  to  speak  in  a  husky  whisper.  There  is  a  hoarse  strid- 
ulous  cough,  with  more  or  less  abundant  muco-purulent  expect- 
oration frequently  streaked  with  blood  and  of  a  fetid  odor.  In- 
spiration and  expiration  are  often  accompanied  by  a  whistling  or 
stridulous  sound.  In  some  cases  the  act  of  swallowing  fluids  or 
solids  excites  spasm  of  the  glottis.  Talking  is  very  fatiguing.  In 
the  morning  the  most  severe  paroxysms  of  coughing  and  strain- 
ing are  experienced :  the  secretion  accumulates  during  the  night, 
and  is  detached  with  difficulty,  so  that  much  coughiug,  hawking 
and  straining  are  necessary  (Loomis  and  Bartholow). 

Treatment. — Mild  astringent  solutions  of  alum,  perchloride 
of  iron,  tannin  or  sulphate  of  zinc,  from  one  to  twenty  grains  to 
the  ounce  of  water  may  be  used.  For  steam  inhalations,  a  few 
drops  of  oil  of  creosote,  oil  of  pine  or  oil  of  juniper,  added  to 
half  a  pint  of  water  at  a  temperature  of  150°  F.,  maybe  enrploy- 
ed.  The  spray  and  steam  inhalations  may  be  repeated  three 
times  daily.  A  solution  of  carbolic  acid  (two  grains  to  an  ounce 
of  water)  as  a  spray,  may  be  used  with  benefit  in  cases  where 
the  laryngeal  secretion  has  a  fetid  odor  (Loomis).  The  treat- 
ment of  chronic  catarrhal  laryngitis  of  phthisis  and  syphilis  is 
the  same  as  in  simple  chronic  laryngitis,  with  the  constitutional 
treatment  of  those  affections  added. 


LARYNGITIS LEAD    POISONING.  .305 

PRESCRIPTIONS  FOR  LARYNGITIS, 

R     Sodii  biboratis gr.  viij. 

Aqua> S  i  ]  - 

Aqua?   cologniensis  gtt.  x. — M. 

Sig. :     Use  frequently  with  atomizer  as  a  spray  (chronic  form). 

— Sajous. 

R     Potassii  permanganatis gr.  ij. 

Aqua  destillatas 3ij.— M. 

Sig.:     Use  with  atomizer  several  times  daily.     (In  fetid  variety 
of  chronic  laryngitis).  — Sajous. 

R     Tinct.  aconiti  radicis 3ss. 

Sig. :     One  drop  in  water  every  hour.     When  it  has  existed  some 
days  then  give  the  following: 

R     Vini  mariani Oj. 

Sig.:     A    wineglassful  every  three  hours,    with    absolute  rest  of 
voice.     (In  acute  laryngitis).  — Sajous. 

LEAD    POISONING. 

Is  a  morbid  condition  produced  by  the  introduction  of  the 
salts  of  lead  into  the 'system,  either  through  the  mucous  surface 
or  the  skin  (Loomis). 

Causes. — The  sources  of  leadqDoisoning  are  numerous. 
Painters  and  workers  in  lead  are  those  most  frequently  affected. 
Drinking  water,  wines,  and  ales  often  become  impregnated  with 
it.  The  application  of  lead  powder  as  a  cosmetic  to  the  face  and 
neck  has  caused  lead-poisoning.  Some  persons  are  more  suscep- 
tible to  its  poisonous  influence  than  others.  Lead  taken  as  a 
medicine,  a  dressing  for  the  hair  containing  acetate  of  lead,  a  lo- 
tion for  the  eye,  and  vaginal  injections  containing  lead  may  pro- 
duce lead-poisoning.  Lead  may  be  inhaled  in  sufficient  quanti- 
ties to  produce  lead-poisoning,  as  in  paper  staining,  grinding  of 
colors,  plumbing,  shot-making,  etc.,  lead-poisoning  has  re- 
peatedly occurred  from  sleeping  in  newly- painted  rooms.  Soda- 
water  may  contain  lead,  and  articles  enclosed  in  lead  foil  may 
produce  poisoning.  Children  may  be  poisoned  by  sucking  lead 
toys  (Flint  and  Loomis). 

Symptoms. — In  chronic  lead- poisoning,  the  general  health  is 
impaired.     The  skin  becomes  sallow,  dry  and  harsh.     There  are 


306  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

dyspepsia,  loss  of  appetite,  and  constipation.  A  blue  line  forms 
along  the  edge  of  the  gums  adjoining  the  teeth.  The  most  im- 
portant symptom  is  intestinal  colic.  It  has  been  called  painters' 
colic,  plumbers'  colic,  colica  pictonum,  and  dry  bellyache. 
Pain  is  oftenest  referred  to  the  region  of  the  umbilicus.  It  is 
a  dull  aching  pain,  sometimes  acute.  Patients  are  inclined  to  lie 
upon  the  belly  with  a  folded  pillow  placed  under  them  over  the 
seat  of  pain.  There  may  be  nausea  and  vomiting.  Hiccough 
and  eructations  of  gas  are  common.  The  urine  is  scanty,  and 
micturition  is  sometimes  difficult  and  painful.  There  is  no  fever. 
The  most  frequent  of  the  nervous  affections  is  drop -wrist  from 
paralysis  of  the  extensors  of  the  forearm.  There  is  no  loss  of 
sensation  in  the  paralyzed  limb.  The  diagnosis  can  be  made  by 
the  history  of  the  case,  and  from  the  symptoms  (Flint  and 
Looinis). 

Treatment. — Remove  the  patient  from  all  sources  of  lead- 
poisoning.  The  bowels  should  be  kept  freely  open.  Five  to  ten 
grains  of  iodide  of  potassium  three  times  daily  should  be  given.  A 
drachm  of  dilute  sulphuric  acid  in  a  quart  of  sweetened  water  may 
be  taken  in  twenty-four  hours.  Faradization  for  ten  or  fifteen 
minutes  three  times  a  clay  for  two  or  three  months  is  the  only 
effectual  remedy  for  restoring  the  paralyzed  muscles.  Chloro- 
form given  by  the  mouth  and  applied  over  the  abdomen  some- 
times acts  promptly  and  efficiently  in  relieving  the  pain.  Opium 
in  some  form  may  be  required  to  relieve  the  pain.  The  warm 
bath  is  useful  as  a  palliative  soothing  measure  (Flint  and 
Looinis). 

PRESCRIPTIONS  FOR  LEAD=P0IS0NING. 

R     Magnesii  sulphatis si- 

Acidi  sulphurici  dil  3,j. 

Aquae  §iv. — M. 

Sig. :     A  tablespoonful  three  times  daily,  preceded  by  five    to  ten 
grains  of  potassium  iodide.  — Brunton. 

R     Morphias  sulphatis gr.  iv. 

Aquse  destillatse  3ij- — M. 

Sig. :     Five  to  ten  minims  hypodermically  repeated  every  fifteen 
minutes  till  relieved.  —  Bartholow. 


LEPROSY.  307 

R     Pulv.  opii gr.  xij. 

Ext.  belladonnas gr.  ij . 

Olei  tiglii   gtt.  xij. — M. 

Ft.  massa  et.  in  pil.  no.  xii  div. 
Sig. :      A  pill  every  two  hours  until  relieved.  — Loomis. 

LEPROSY. 

Is  an  infectious  and  contagious  disease  of  very  ancient  date, 
characterized  by  nodules  which  occur  most  frequently  in  the 
skin. 

It  has  been  endemic  in  Egypt,  India  and  China.  It  was 
prevalent  among  the  Hebrews. 

Leper  houses,  for  the  isolation  of  the  diseased,  were  estab- 
lished in  the  seventh  century.  There  was  an  intense  dread  of 
the  disease,  and  lepers  had  to  wear  a  special  costume,  usually'  a 
long  gray  gown  with  a  hood  drawn  over  the  face;  they  carried  a 
wooden  clapper  to  give  warning  of  their  approach.  They  were 
not  allowed  to  enter  churches,  inns,  mills  or  bakehouses,  nor  to 
touch  healthy  persons,  nor  to  eat  with  them,  nor  to  wash  in  the 
streams,  nor  to  walk  in  narrow  foot  paths.  A  leper  woman, 
quick  with  child,  was  buried  alive.  Leprosy  is  still  common  all 
over  the  east,  and  there  are  leper  villages  in  China,  Japan,  Persia 
and  Crete.  The  disease  is  also  common  in  Africa,  India,  Mada- 
gascar, St.  Helena,  Maderia,  Canaries,  Azores,  West  Indies, 
Mexico,  Brazil,  Central  America,  Norway  and  the  Hawaiian 
Islands.     Sporadic  cases  occur  in  England  and  France. 

Causes. — It  is  an  hereditary  disease,  and  there  is  the  strong- 
est repugnance  to  marriage  into  a  family  where  leprosy  is  known 
to  exist.  It  is  an  infectious  and  contagious  disease.  It  never 
originates  de  novo.  The  lesions  of  leprosy  contain  characteristic 
bacilli  which  would  seem  to  be  the  real  cause.  Climate,  poverty 
and  bad  hygiene  are  predisposing  causes  (Anderson). 

Symptoms. — Leprosy  appears  as  a  constitutional  disease, 
marked  externally  by  the  deposition  of  a  peculiar  albuminous 
substance  in  the  skin,  appearing  as  discolored  patches  and  no- 
dules, and  effecting  the  nerve  centres  and  peripheral  nerves. 
Leprosy  has  been  divided  into  two  forms,  viz:  the  tuberculous 
and  the  anaesthetic.     The    tubercular   is    characterized   by    <lis- 


308  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

colored  patches  and  nodules,  and  the  anaesthetic  by 
depositions  in  the  nerve  centres.  After  an  uncertain 
prodromal  stage,  there  will  appear  successive  out- 
breaks of  the  eruption,  in  the  form  of  blotches  on  the  skin,. 
which  come  and  go  before  tubercles  make  their  appearance.  The 
tubercles  appear  on  the  site  of  the  patches.  When  the  tubercles 
are  fully  formed,  they  are  brown  and  the  skin  is  thickened,  and 
the  hyperesthesia  is  succeeded  by  anaesthesia.  Sometimes  there 
is  an  irregular  thickening  of  the  entire  skin  of  the  face.  Tuber- 
cles are  most  frequently  developed  on  the  head,  face,  ears,  nose, 
extremities,  the  mammary  gland  and  nipple,  the  scrotum  and 
around  the  anus  and  vagina.  There  is  but  little  pain  in  this 
stage  of  the  disease.  The  tubercles  are  extremely  apt  to  ulcerate 
from  personal  uncleanliness,  and  then  the  odor  of  the  patient  is 
extremely  offensive.  Ulceration  most  frequently  commences  at  the 
tips  of  the  ears,  then  at  the  toes  and  fingers,  and  it  often  termi- 
nates in  necrosis,  the  fingers  and  toes  dropping  off  joint  by  joint 
leaving  a  well  healed  stump.  Ulceration  and  sloughing  may 
take  place  with  but  very  little  pain.  In  about  nine  years  the 
disease  reaches  its  climax,  the  whole  system  is  poisoned,  and  the 
patient  presents  an  aspect  the  most  loathsome  that  can  be  im- 
agined. The  natural  duration  of  the  disease  is  about  fifteen 
years  (Anderson). 

Treatment. — The  disease  is  incurable,  and  the  treatment  is 
merely  palliative.  To  cure  the  disease  the  ancient  kings  of 
Egypt  bathed  in  the  blood  of  slaves.  The  Hindoos  drank  cows1 
urine.  Chaulmoogra  oil  and  Gurjon  oil  are  the  best  remedies 
known  for  leprosy. 

LEUCOCYTH/EMIA. 

Called  also  leucaemia,  is  a  disease  characterized  by  the 
enormous  increase  of  the  white  corpuscles  of  the  blood,  accom- 
panied by  enlarged  spleen  and  enlarged  lymphatic  glands 
(Bartholow). 

Causes. — The  real  cause  of  this  malady  is  unknown.  It 
occurs  at  all  ages  and  conditions,  but  is  most  frequent  between 
thirty  and  forty- five.  It  is  twice  as  frequent  in  men  as  in  women. 
In  women  there  seems  to  be  a  connection  between  the  generative 


LE.UCOCYTBLEMIA.  309 

organs  and  this  disease.  Cold,  wet,  and  all  anti-hygienic  condi- 
tions predispose  it.  The  morbid  alterations  begin  in  the  spleen, 
then  attack  the  lymphatic  glands,  then  the  marrow  of  the  bones 
and  finally  become  general  (Bartholow  and  Loomis). 

Symptoms.—  Leucocythaemia  develops  gradually.  There  is 
usually  a  history  of  the  gradual  appearance  of  weakness,  mental 
and  physical  anaemia,  ringing  in  the  ears,  vertigo  and  palpita- 
tion. The  patient  becomes  pale  and  assumes  a  waxy  appear- 
ance. In  about  eighteen  months,  the  anaemia  becomes  profound, 
the  lymphatics  of  the  neck,  groin,  or  other  superficial  parts  are 
found  to  be  somewhat  enlarged.  The  spleen  is  also  enlarged. 
There  are  dyspnoea  and  at  times  profuse  sweating,  f everishness 
toward  evening,  rapid  pulse,  oedema  of  the  ankles  and  puffiness 
of  the  eyelids.  The  least  cut  bleeds  severely.  A  soft  blowing 
murmur — anaemic  murmur — is  heard  at  the  base  of  the  heart.  In 
leucocythaemia  the  blood  is  jDaler  than  normal.  The  contrast  is 
nicely  shown,  when  a  drop  of  the  blood  is  compared  with  a  drop 
of  healthy  blood,  on  a  piece  of  white  linen.  In  this  disease 
there  is  one  white  corpuscle  to  six  of  the  red.  There  is  consti- 
pation at  first,  and  finally  diarrhoea  persists.  It  is  a  chronic 
malady,  and  the  average  duration  of  the  whole  disease  is  two 
years  (Bartholow  and  Loomis). 

Prognosis. — All  cases  are  fatal. 

Treatment. — Must  be  symptomatic,  as  we  have  no  specific 
for  this  disease.  Quinia,  iron  and  ergotin  can  be  given  together 
in  pill  form;  five  grains  of  quinia,  one  grain  of  reduced  iron,  and 
two  grains  of  ergotirj  should  be  administered  three  times  a  day. 
Electricity  should  be  applied  to  the  splenic  region.  Good  results 
are  obtained  from  the  local  application  of  the  ointment  of  the 
biniodide  of  mercury  to  the  splenic  region.  The  ointment  should 
be  rubbed  in  daily,  before  a  bright  tire,  until  the  skin  beo-ins  to 
vesicate,  then  discontinued  for  a  few  days.  As  the  blood  is  im- 
poverished in  this  disease,  careful  alimentation  is  of  the  greatest 
importance.  Fats,  starches  and  sugars  should  be  excluded  from 
the  diet,  and  the  patient  fed  on  fresh  meats,  milk,  eggs  and  fish. 
Pepsin  and  muriatic  acid  should  be  administered  after  each  meal. 
Fowler's  solution,  and  the  compound  syrup  of  the  hvpophos- 
phites  may  be  given  with  benefit  (Bartholow  ). 


310  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  LEUCOCYTMMIA. 

R     Aeidi  nitro-mnriatici  dil §j. 

Sig. :     Ten  to  twenty  drops  in  a  wineglassful  of  water  thrice  daily. 

— Hartshorne. 

R     Quinise  sulphatis oj. 

Ferri  sulph.  exsiccat £iss. — M. 

Ft.  massa  et  in  pil.  no.  xxx.  div. 
Sig.:     Four  or  five  pills  daily.  — Bartholow. 

LYMPHADENOMA. 

Called  also  Hodgkin's  disease,  because  it  was  first  described 
by  Dr.  Hodgkin  in  1832;  known  also  as  pseudo-leucocythaemia 
or  leukaemia,  is  a  disease  characterized  by  enlargement  of  the 
lymphatic  glands  and  spleen,  and  by  progressive  anaemia,  but 
without  an  increase  of  white  corpuscles  in  the  blood  (Bar- 
tholow). 

Causes. — Are  unknown.  It  is  not  hereditary.  It  may  come 
on  in  a  person  in  apparently  perfect  health;  it  is  more  common 
in  men  and  in  youth  and  old  age  than  in  the  middle  period  of 
life;  but  it  may  occur  at  any  age  (Bartholow). 

Symptoms. — The  lymphatic  glands  in  the  neck,  armpit  or 
groin  are  first  attacked,  and  become  greatly  enlarged.  Unlike 
scrofulous  glandular  enlargement  they  undergo  no  caseation, 
suppuration  or  retrogressive  changes.  All  the  lymphatics  of  the 
body  may  be  enlarged.  The  spleen  is  enlarged.  Emaciation 
and  anaemia  aie  marked  and  progressive.  There  may  be  dull 
pains  from  pressure  on  the  sensory  nerves.  The  pulse  is  small 
and  rapid.  There  is  usually  fever  in  the  evening.  The  number 
of  white  corpuscles  in  the  blood  is  not  in  excess  of  the  normal  in 
the  majority  of  cases.  The  course  of  the  disease  is  chronic.  One 
year  is  its  average  duration;  two  months  and  three  years  are  its 
extremes  (Bartholow  and  Loomis  ). 

Differential  Diagnosis. — Lymphadenoma  may  be  mistaken  for 
leucocythaemia.  In  leucocythaemia  the  changes  in  the  glands 
succeed  to  those  in  the  blood,  whereas  the  glandular  enlarge- 
ment is  first  in^Hodgkin's  disease.  By  microscopic  examination, 
when  the  ratio  between  the  white  and  red  corpuscles  reaches  one 


LYMPHADEXOMA LEUCOKRHCEA.  311 

to  twenty  the  case  must  be  regarded  as  one  of  leucocythaemia 
(Bartholow  and  Loomis). 

Prognosis. — Is  bad. 

Treatment. — Fowler's  solution  increased  to  ten,  fifteen  or 
twenty  minims,  thrice  daily,  according  to  the  forbearance  of  the 
stomach  seems  to  be  effective;  and  one  to  five  minims  in  distilled 
water  may  be  injected  into  the  enlarged  glands.  Iodide  of  po- 
tassium may  be  tried.  The  syrup  of  the  iodides  of  iron  and 
manganese  has  seemed  to  do  good.  Cod-liver  oil  is  useful  as  a 
nutrient  and  tonic  (Bartholow). 

LEUCORRHCEA. 

Is  a  morbid  alteration  and  exaggeration  of  the  physiological 
uterine  and  vaginal  secretions.  In  a  state  of  health  these  parts 
secrete  in  small  -quantity  a  mucous  liquid  which  always  contains 
a  few  leucocytes;  As  soon  as  this  has  become  abundant  and 
purulent,  it  is  morbid  and  constitutes  a  leucorrhcea.  Leucorrhoea 
is  also  called  whites,  and  is  a  catarrhal  condition  of  the  vagina 
and  uterus. 

The  purulent  discharge  may  be  from  two  sources,  the  uterus 
or  the  vagina.  Vaginal  leucorrhoea  may  often  be  found  alone;  it 
may  be  a  discharge  of  very  thin  fluid  of  a  milky  appearance, 
which  does  not  stain  the  linen  much,  or  it  may  be  charged  with 
pus  and  be  of  a  greenish -yellow  color;  its  reaction  is  acid.  Leu- 
corrhcea from  the  body  of  the  uterus  is  of  a  somewhat  viscid 
nature;  that  from  the  cervix  is  jelly  like  and  in  the  normal  state 
is  transparent,  like  the  unboiled  white  of  egg,  staining  the  linen 
strongly;  in  disease  it  is  of  a  greenish-yellow  color.  Its  reaction 
is  alkaline.  The  leucorrhceal  secretion  is  constantly  produced, 
but  is  voided  a  little  at  a  time. 

Causes. — Leucorrhoea  may  depend  simply  on  a  general  de- 
bilitated condition,  as  anaemia,  chlorosis,  etc.  This  symptomatic 
form  is  so  frequent  that  Marc  d'Espine  has  claimed  to  find  it  in 
two-thirds  of  the  women. 


312  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  LEUCORRHCEA. 

R     Aluminis gj. 

Zinci  sulphatis jss. 

Sodii  biboratis  gr.  iv. 

Aquas  rosse gviij .  — M. 

Sig.:     Use  as  injection.  — Bartholow. 

According  to  Bartholow,  uterine  and  vaginal  leucorrhcea,  ul- 
cerations, and  erosions  of  the  cervix  uteri,  are  quickly  improved 
by  the  topical  application  of  the  fluid  extract  of  hydrastis, 
which  may  be  used  in  an  undiluted  state.  The  same  author 
knows  of  no  more  effective  application  in  leucorrhoea  than  tan- 
nin and  iodoform  applied  in  the  dry  way,  well  packed  around 
the  cervix  uteri.  Carbolic  acid  diluted  and  used  with  care  is  an 
excellent  deodorizer  when  the  discharges  from  the  vagina  are 
fetid.  According  to  Ringer,  a  drachm  of  bicarbonate  of  potash, 
soda,  or  alum  to  a  pint  of  water  is  a  useful  injection  to  check 
leucorrhoea,  when  this  discharge  depends  on  an  increased  secretion 
of  the  glands  of  the  os  uteri.  The  alum  solution  constrings  the 
parts,  and  sometimes  causes  severe  cramp-like  pains. 

PRESCRIPTIONS  FOR  LEUCORRHCEA. 

R     Acidi  tannici ,|iv. 

Gly  cerina gx  vj . — M. 

Sig. :     A  tablespoonful  into  a  quart  of  tepid  water,  used  as  a   va- 
ginal injection  for  five  minutes,  night  and  morning.    — T.  G.  Thomas. 

R     Sodii  bicarbonatis 5j  • 

Tinct.  belladonna? §ij. 

Aquae Oj. — M. 

Sig.:     Use  as  a  va.inal  wash.  — Ringer. 

R     Tinct.  sulphatis. 

Aluminis    sulphatis aa 5iss. 

Glycerina §vj . — M. 

Sig.:     A  tablespoonful  to  a  quart  of  water,  as  a  vaginal  injection. 

— Thomas. 

R     Acidi  boracici  5j- 

Aqua1  ferventis Ovj. — M.  Ft.  lotion. 

Sig. :     To  be  used  as  a  vaginal  injection.  — Ringer. 


LICE.  313 

R     Potassii  permanganatis 5ss. 

Aqua? |x  v. 

Sig.:     For  vaginal  injection.     In  fetid  discharge.      — Bartholow. 

R     Sodii  biboratis 5ij. 

Sig.:     A  teaspoonful  to  a  pint  of"  water  as    a   vaginal  wash.     For 
leucorrhcea  of  pregnancy.  — Parvin. 

R     Potassii  chloratis §ij. 

Sig. :     A  teaspoonful  to  a  pint  of  water  as   a  vaginal  injection. 
(In  simple  cases.)  — Parvin. 

LICE. 

There  are  three  varieties  of  this  affection,  each  dependent 
upon  a  separate  parasite,  namely:  1.  The  pediculns  corporis, 
which  is  met  with  exclusively  upon  non-hairy  parts.  It  secretes 
itself  among  the  folds  of  the  clothing,  and  is  rarely  seen  upon 
the  body  except  when  feeding.  2.  The  pediculus  capitis,  which 
is  met  with  exclusively  upon  the  head.  And  3.  The  pediculus 
pubis,  which  is  met  with  on  all  hairy  parts  except  the  head,  but 
the  hair  on  the  pubis  and  neighboring  parts  is  its  favorite  hunt- 
ing ground.  The  crawling  and  biting  of  these  parasites  produce 
irritation  and  itching,  to  relieve  which  the  part  is  scratched 
(Anderson). 

Treatment. — Is  very  simple.  The  most  effectual  remedies 
are  carbolic  acid,  sulphur,  mercury,  staphisagria,  sabadilla  and 
pyrethrum,  the  essential  oils  and  alcohol.  The  following  for- 
mulae are  good  : 

R      Acidi  carbolici 31J. 

Spts.  rosmarini 3j . 

Spts.  rectificati 3ss;. 

Aquae  destillatse ad §vj. — M. 

Sig.:     Sponge  the  affected  parts  night  and  morning. — Anderson. 

R     Hy drargyri  perchloridi gr.  xij . 

Spts.  rectificati 3j. 

Aquas  destillatee 5v. 

Olei  rosa? 2TTj . — M. 

Sig.:     Sponge  the  affected  part  night  and  morning.    — Anderson. 

R     Pulv.  staphisagria SJ. 

Adipis siv. 

Olei  rosmarini gtt.  xxx. — M. 

Sig.:     Apply  once  daily.  — Anderson. 


314  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

LICHEN. 

Is  a  papular  inflammation  of  the  skin.  It  consists  of  minute 
conical  papula?,  generally  of  reddish  color,  and  occurring  in 
clusters.  It  is  most  frequently  encountered  in  the  summer 
months  and  in  adults,  and  often  in  persons  who  are  in  s;ood 
health,  but  who  have  been  exposed  to  much  fatigue  or  anxiety. 
Disordered  digestion  may  j3roduce  it.  It  is  commonly  chronic 
(DaCosta). 

Treatment. — Arsenic  sometimes  relieves  lichen  and  other 
obstinate  skin  affections  (Ringer).  Cantharides  is  useful  in 
licheu.  An  ointment  composed  of  half  a  drachm  of  chloroform 
to  an  ounce  of  lard  will  often  allay  the  itching  of  lichen  or  of 
urticaria.  Patches  of  obstinate  lichen  and  psoriasis,  especially 
of  the  hands,  even  when  not  syphilitic,  will  sometimes  yield  to 
mercury  treatment.  The  calomel  and  nitrate  of  mercury  oint- 
ment may  be  mixed,  and  the  addition  of  tar  ointment  sometimes 
increases  the  efficacy  of  this  combination  (Ringer).  In  lichen 
psoriasis,  eczema,  ichthyosis,  urticaria,  prurigo  and  scabies  and 
the  warm  bath  may  be  employed  with  much  benefit. 

PRESCRIPTIONS  FOR  LICHEN. 

R     Crete  prseparata? 3vi. 

Sulphuris  sublimati 

Olei  cadini — aa 3ix. 

Saponis  nigris ; . . 

Aclipis — aa gxxv. 

(Melt  the  lard  and  then  add  other  ingredients.) 
Sig.:     Apply  locally.  — Hebra. 

R     Sodii  arseniatis gr.  iss. 

Aqua?  destillata? jxxv. — M. 

Sig.:     A  teaspoonful  every  morning  at  meal  time.  — Vidal. 

R     Glyceriti  amyli 3v. 

Pulv.  acidi  tartaric! gr.  xv. — M. 

Sig.:     Apply  locally.  — Vidal. 


LOCOMOTOR    ATAXIA.  315 

LOCOMOTOR  ATAXIA. 

Called  also  Duchenne's  disease,  known  also  as  posterior 
spinal  sclerosis,  tabes  dorsalis,  gray  degeneration  of  the  posterior 
columns,  and  leuko- myelitis  posterior  chronica,  is  one  of  the 
most  frequent  diseases  of  the  spinal  cord,  and  is  a  form  of  myel- 
itis which  does  not  extend  transversely,  but  longitudinally,  and 
is  limited  to  the  posterior  columns  (Bartholow). 

Causes. — An  inherited  tendency  is  probably  the  chief  cause. 
It  occurs  between  twenty  and  sixty,  but  is  most  frequent  between 
thirty-five  and  fifty.  It  attacks  males  six  times  as  often  as 
females.  Exposure  to  cold  and  dampness,  fatigue  and  depress- 
ing moral  emotions  favors  its  development.  Sexual  excesses, 
rheumatism,  syphilis,  excessive  use  of  tobacco  and  blows  on  the 
spine  are  predisposing  causes  (Bartholow  and  Loomis). 

Symptoms. — The  distinctive  characteristic  of  the  affection  is 
impairment  or  loss  of  the  ability  to  combine  and  direct  volun- 
tary muscular  movements. 

Stages. — 1.  The  initial  period  or  first  stage.  2.  The  ataxic 
period,  or  second  stage.  And  3.  The  paralytic  or  third  stage. 
During  the  first  stage  or  period,  there  are  sharp,  tearing,  light- 
ning pains  in  the  lower  limbs,  dysuria,  incontinence,  spermatorr- 
hoea, nocturnal  pollutions,  excitement  of,  or  loss  of  sexual  desire, 
a  sense  of  weariness  in  the  limbs  and  nausea  and  vomiting,  at- 
tended by  severe  and  paroxysmal  aching  in  the  stomach.  A 
sense  of  numbness  and  formication  in  the  limbs  is  common  in  this 
period.  There  may  be  a  girdle  sensation,  not  only  about  the 
waist,  but  also  in  the  limbs — chiefly  about  the  knee  and  ankle. 
Rectal  and  urethral  colic  are  frequent.  The  pains  during  this 
period  are  usually  in  the  feet  and  legs,  but  they  may  have  their 
seat  in  the  back,  stomach,  intestine  or  bladder.  At  first  they  do 
not  come  on  often,  and  are  of  short  duration.  The  muscles  of 
the  eyes  may  be  affected,  causing  double  vision,  or  strabismus, 
which  may  last  a  few  days,  and  then  disappear.  Sometimes  the 
patient  will  complain  of  a  sensation  of  some  soft  substance  be- 
tween the  feet  and  the  ground.  One  portion  of  the  surface  may 
be  anaesthetic,  another  hypersesthetic.  The  pupil  on  one  side 
may  be  contracted  to  the  size  of  a  pin's  point,  showing  paralysis 


316  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

of  the  sympathetic,  and  on  the  other  side  dilated.  Oftener  both 
pupils  are  contracted.  A  symptom  which  possesses  considerable 
diagnostic  value  is  the  absence  of  contraction  of  the  pupil  on 
exposure  to  light,  while  there  is  normal  contraction  in  the  acts 
of  accommodation;  this  is  called  the  "Argyll -Robertson   pupil." 

The  "  Knee-jerk,"  or  patellar  tendon  reflex,  is  found  to  be 
absent  in  76  per  cent,  of  the  cases,  according  to  Buzzard.  The 
duration  of  this  stage  varies  from  a  few  months  to  several  years, 
and  then  begin  the  symptoms  characteristic  of  the  second  or 
ataxic  stage.  The  ataxia  is  generally  first  manifested  in  the 
lower  extremities.  The  legs  are  thrown  forward  with  a  quick, 
jerking  movement,  and  the  feet  are  brought  to  the  ground  on 
the  heels  with  force  and  are  liable  to  strike  against  each  other. 
The  patient  is  unable  to  button  or  unbutton  clothes,  when  the 
upper  extremities  are  affected.  There  may  be  double  vision  and 
night-blindness.  A  symptom  even  when  the  affection  is  slight, 
is  inability  to  stand  with  the  feet  in  apposition  and  the  eyes 
closed.  The  patient's  eyes  are  directed  to  the  feet  and  ground 
in  walking.  Impotence  occurs  in  this  stage.  The  patellar 
reflex  is  wanting  and  this  is  diagnostic.  Cutaneous  sensibility 
is  more  or  less  impaired.  During  this  period  the  joints  some- 
times rapidly  swell.  In  the  third  or  paratytic  stage,  notable 
paralysis  is  added  to  the  ataxia.  The  muscles  waste,  the  patient 
falls  into  a  cachectic  state,  cystitis  and  bed-sores  occur,  and 
death  takes  place  from  exhaustion.  During  this  third  stage, 
there  is  always  complete  impotence,  and  loss  of  sensation  about 
the  rectum.  Locomotor  ataxia  is  a  non-febrile  disease.  The 
whole  duration  of  the  disease  is  on  the  average  seven  years,  but 
may  continue  thirty  years.  The  shortest  duration  is  three  years 
(Bartholow,  Flint  and  Loomis). 

Differential  Diognosis. — Locomotor  ataxia  may  be  confounded 
with  paraplegia,-  multiple  cerebro- spinal  sclerosis,  cerebellar  dis- 
ease, chronic  myelitis,  and  chronic  spinal  meningitis.  In  para- 
plegia, there  is  true  paralysis;  the  limbs  merely  dragged  in  walk- 
ing; there  is  no  resistance  to  artificial  movement;  the  nutrition  of 
the  muscles  is  greatly  impaired;  neuralgic  pains  are  absent,  and 
there  are  no  ocular  symptoms.  In  ataxia  these  symptoms  are  re- 
versed.    In  multiple  cerebro -spinal  sclerosis,  there  are  a  peculiar 


LOCOMOTOR    ATAXIA.  317 

shaking  tremor,  impairment  of  voice  and  speech,  and  nystagmus. 
In  ataxia  these  symptoms  are  absent.  In  ataxia  there  are  iron 
band  sensations,  bladder  symptoms,  the  lightning-like  pains  and 
the  heel  walk,  all  of  which  are  absent  in  the  former  disease.  In 
cerebellar  disease  there  is  vertigo.  The  patient  can  stand  and 
walk  better  with  his  eyes  shut  than  open.  There  is  absence  of 
neuralgic  pains;  and  headache,  vomiting  and  convulsions  are 
prominent  symptoms.  In  ataxia  this  is  not  so.  In  chronic 
myelitis  there  are  no  disorders  of  co-ordination.  In  chronic 
myelitis  the  limbs  are  dragged,  and  the  ocular  symptoms  are  ab- 
sent. The  reverse  in  ataxia.  In  meningitis  there  is  pain  in- 
creased on  pressure,  slight  paralysis,  but  no  inco- ordination,  and 
no  ocular  symptoms  (Loomis). 

Prognosis. — Unfavorable. 

Treatment. — About  one  grain  a  clay  in  divided  doses  of 
nitrate  of  silver  is  recommended.  The  galvanic  current  is  nearly 
always  of  service.  Some  cases  will  be  benefited  by  the  iodides, 
others  by  the  bromides.  Strychnine,  phosphorus,  arsenic,  the 
chlorides  of  gold,  sodium,  and  barium,  belladonna  and  ergot  all 
have  been  recommended.  The  patient  should  remain  at  rest  and 
not  expose  himself  to  cold  or  wet,  and  should  wear  flannel  next 
the  skin.  Coffee,  tea,  tobacco  and  alcoholic  stimulants  should 
be  given  up.  Cold  water  baths  are  favorable  (Bartholow  and 
Loomis). 

PRESCRIPTIONS  FOR  LOCOMOTOR  ATAXIA. 

R     Ext.  physostigmatis gr.  x. 

Ext.  gentian® gr.  xL. — M. 

Ft.  massa  et  in  pil  no.  100  div. 
Sig.:     One  pill  every  three  hours.  — Murrell. 

R     Antifebrin 3J. 

In  pulv.  no.  xv.  div. 
Sig.:     One  powder  every  half  hour  for  two  doses,  then  every  four 
hours. 

R     Strychnia?  sulphatis . .  .gr.  iss. 

Syr   hy pophosphiti 3xij . — M. 

Sig.:     A  teaspoonful  thrice  daily.  — DaCosta. 


318  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

LUMBAGO.     (See  Muscular  Rheumatism.) 
LUPUS. 

Is  a  chronic  tubercular  skin  disease.  In  lupus,  a  tissue  is 
formed  like  granulation  tissue.  Tubercles  form,  which  may 
ulcerate,  and  are  of  a  dull  red  color.  When  they  heal,  they 
leave  a  whitish  scar  (DaCosta). 

Causes. — The  disorder  occurs  in  syphilis,  or  iu  scrofulous 
persons.  It  appears  often  in  childhood,  and  is  attended  with 
some  pain  and  itching,  and  pursues  a  very  slow  course.  The 
nose  and  cheeks  are  the  favorite  sites.  In  strumous  subjects, 
lupus  has  a  warty  appearance.  Some  hold  that  lupus  is  the 
offspring  of  syphilis  in  the  parents  (DaCosta). 

Treatment. — Anti- strumous  remedies  should  be  given.  Our 
sheet-anchor  in  most  cases  is  cod-liver  oil  given  for  a  Ions:  time. 
Next  to  cod-liver  oil  must  be  placed  phosphorus.  Arsenic  may 
be  given,  also  the  syrup  of  the  iodide  of  iron.  Nitrate  of  silver 
should  be  applied  locally  (Anderson). 

PRESCRIPTIONS  FOR  LUPUS. 

R     Zinci  chloridi 

Antimonii  chloridi aa gr.  xx. 

Pulv.  iridis  florentinae  rad gr.  x. 

Acidi  hydrochlorici  puri ZHx. — M. 

Sig. :     Use  as  a  caustic,  spread  on  linen  strips  and  leave  on  24 
hours.  — Kaposi. 

R     Acidi  pyrogallici 5j- 

Cerati  simplicis six. — M. 

Sig. :     Apply  locally.  — Kaposi. 

R     Acidi  lactici  puri §j. 

Sig.:     Apply  to  ulcer  on  absorbent  cotton.  — Wichmann. 

R     Iodini 

Potassii  iodidi aa gr.  xv. 

Glycerine ITT.  xxx. — M. 

Sig. :     Apply  locally.  — Kaposi. 


LIPOMA LACTATION.  319 

LIPOMA. 

Is  a  tumor  formed  of  a  fat  tissue.  The  fat  tissue  occurs  in 
lobules  and  is  similar  to  normal  fat.  Fatty  tumors  may  undergo 
partial  calcification.  They  are  usually  sharply  circumscribed, 
but  may  infiltrate  surrounding  tissue.  They  are  frequently  pe- 
dunculated, and  sometimes  grow  to  enormous  size,  and  may  ulcer- 
ate. They  are  usually  single  but  may  be  multiple.  They  are 
the  most  common  of  tumors.  They  are  benign,  or  innocent 
tumors,  not  forming  metastases. 

Occurrence. — They  occur  at  all  periods  of  life  from  infancy 
to  old  age,  and  are  even  congenital.  They  are  more  common  in 
the  female.  As  a  rule,  these  tumors  are  encapsuled.  They  are 
soft,  movable  and  free  from  pain. 

Situation. — Their  most  usual  situation  is  the  back  of  the 
neck  and  shoulders. 

Cause. — Unknown . 

Diagnosis.— Not  difficult.  The  tumor  will  feel  more  or  less 
firm  and  made  uj3  of  lobes.  The  skin  is  usually  loose  over  the 
tumor. 

Treatment. — When  no  necessity  exists  for  their  removal, 
tumors  should  be  let  alone.  When  large,  unsightly  and  grow- 
ing, they  should  be  removed  by  excision  (Bryant  and  Prudden). 

LOCK=JAW.     (See  Trismus.) 
LACTATION.     (Excessive.) 

Treatment. — When  it  is  desirable  to  arrest  the  secretion  of 
milk  the  gland  may  be  enveloped  by  a  belladonna  plaster.  A 
more  elegant  method  is  to  envelop  the  breast  in  lint  wet  with 
a  solution  of  atropine,  four  grains  to  the  ounce  of  rose  water.  In- 
named  breasts  may  be  treated  in  the  same  way.  Quinia  has 
been  recommended  in  excessive  secretion  of  milk.  An  ointment 
made  by  boiling  half  an  ounce  of  tobacco  in  eight  ounces  of  lard 
kept  constantly  applied  to  the  breasts,  is  also  said  to  arrest  the 
secretion  of  milk  (Bartholow  and  Ringer). 


320  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

LEAD  COLIC.     (See  Colic). 

LENTIGO.      (See  Freckles). 

LEUCODERMA, 

Called  also  vitiligo,  is  an  affection  characterized  by  an  ab- 
sence of  pigment  at  certain  parts  surrounded  by  portions  of  skin 
in  which  it  has  accumulated  to  an  excessive  degree,  so  that  brown 
patches  are  seen  enclosing  white  ones.  The  white  spots  are  at 
first  circular  in  form,  but  uniting  with  each  other  become  irreg- 
lar  in  shape.  It  may  involve  almost  the  whole  body,  but  is 
usually  confined  to  the  hands,  face  and  neck.  It  is  most  com- 
monly met  with  in  persons  of  color.  It  is  a  rare  affection  (An- 
derson). 

Causes. — Some  hold  that  it  is  a  congenital  affection.  Its 
cause  is  very  obscure,  but  there  can  be  little  doubt  that  it  is 
a  neurotic  affection,  and  probably  dependent  upon  perverted 
innervation  of  the  sympathetic  nerve.  The  exciting  cause  is 
sometimes  apparently  a  lesion  of  some  kind;  as  a  burn,  surgical 
operation,  etc.,  (Anderson). 

Diagnosis. — Leucoderma  is  met  with  in  all  parts  of  the  world. 
The  general  health  of  the  patient  is  unaffected.  The  white 
patches  are  round  and  of  a  dead- white  tint.  There  is  no  altera- 
tion in  the  structure  of  the  skin.    Sensation  is  normal  (Anderson). 

Treatment. — Nerve  tonics,  such  as  phosphorus,  strychnia  and 
above  all  arsenic  should  be  tried  (Anderson). 

MALARIAL  FEVERS. 

Are  characterized  by  their  prevalence  in  certain  regions  of 
the  world  known  to  produce  the  poison  malaria,  by  their  period- 
icity, and  by  the  regular  succession  of  the  cold,  hot  and  sweating 
stages.  There  are  many  varieties  of  malarial  fever  and  they  have 
received  various  names,  such  as  fever  and  ague,  chills,  bilious 
fever,  bilious  remittent,  remittent,  intermittent,  pernicious  inter- 
mittent, congestive,  "mountain  fever  of  Colorado,1'  continued 
malarial,    typho-malarial,    Chickahominy   fever,    "the    shakes/" 


MALARIAL    FEVERS.  321 

swamp  fever,   "Panama  fever,"    "camp   fever1'    and  periodical 
fever  (Bartholow). 

Causes. — All  varieties  of  malarial  fevers  have  a  common 
origin  in  a  poison  which  has  received  the  name  of  miasm,  or 
malaria,  and  which  is  subject  to  certain  variations  in  quantity. 
By  some  this  miasm,  or  malarial  poison,  is  regarded  as  gaseous 
in  its  nature,  by  others  it  is  thought  to  be  a  living  vegetable  or- 
ganism, and  again  others  think  it  a  specific  poison,  having  no 
tangible,  chemical  or  microscopical  constituents.  Certain  proto- 
plasmic bodies  have  been  found  in  the  red  corpuscles  of  malarial 
patients,  which  were  called  "plasmodium  sanguinis  malarise,11 
but  it  is  not  known  whether  they  are  normal  or  are  the  cause  or 
result  of  the  malarial  infection.  But  while  we  do  not  know  the 
true  nature  of  malaria,  yet  we  do  know  something  of  the  circum- 
stances which  are  necessary  for  its  production.  First,  a  certain 
amount  of  vegetable  matter  on  or  in  the  soil  is  absolutely  neces- 
sary. Second,  a  certain  amount  of  moisture  on  or  in  the  soil  is 
indispensable.  Third,  a  certain  degree  of  temperature  is  neces- 
sary. It  cannot  be  developed  below  an  average  temperature  of 
58°  F.  for  the  twenty-four  hours. 

Infected  Regions.— Marshes  are  especially  favorable  to  the 
development  of  this  poison,  and  may  generate  it  for  an  indefinite 
period.  The  Pontine  marshes,  between  Rome  and  Naples,  have 
been  malarial  for  more  than  two  thousand  years.  But  not  all 
marshes  produce  malaria.  The  "Dismal  swamp,11  for  example, 
is  free  from  marsh -miasm,  although  apparently  well  adapted  to 
produce  it.  Its  exemption  is  supposed  to  be  due  to  the  growth 
of  the  cypress -tree.  If  the  marsh  contains  an  abundance  of 
water,  malarial  fevers  are  rare.  If  the  marsh  be  covered  with  a 
thin  sheet  of  water,  or  has  dried  up,  malarial  poison  will 
abound.  As  a  rule,  salt  water  marshes  are  especially  free  from 
malaria,  but  when  salt  and  fresh  water  are  mixed  in  the  marsh, 
the  best  conditions  for  malaria  exist.  Damp  "bottom  lands11  are 
as  fruitful  as  swamps  in  the  generation  of  this  poison.  Another 
Condition  which  favors  the  development  of  malaria  is  the  up- 
heaval of  new  alluvia]  soils  in  cultivating,  or  in  excavating  for 
railroads.  Regions  otherwise  non-malarial  may  have  malarial 
poison  brought  to  them  by  the  waters  of  rivers  which  have  their 


322  A    COMPENDIUM    OF    PRACTICAL     MEDICIJNTE. 

source  in  or  flow  through  malarial  districts,  as  along  the  banks 
of  our  Western  rivers;  or  it  may  be  brought  to  them  by  the 
wind. 

Circumstances  which  are  inimical  to  the  production  of 
malaria  are : 

I.  High  Latitude. — In  this  country  malarial  poison  is  not 
generated  in  higher  latitude  than  that  of  Quebec.  The  limit  of 
its  development  is  63°  north  and  57°  south  latitude.  The  nearer 
the  approach  to  the  Equator,  the  more  severe  the  type. 

II  High  Elevation. — As  a  rule,  it  is  not  generated  above 
-an  elevation  of  1000  feet  above  the  sea,  but  there  are  exceptions 
to  this  afforded  by  the  so-called  "mountain  fever"  of  Colorado, 
of  the  Pyrenees,  and  of  the  mountains  of  South  America. 

III.  Drainage  and  Cultivation. — In  the  majority  of 
marshes,  malaria  can  be  prevented  or  arrested  by  free  drainage. 
Yet  there  are  marshes  upon  which  millions  have  been  expended 
in  drainage  and  which  still  remain  pestiferous,  as  for  example 
the  Jersey  Flats  and  Pontine  marshes. 

IV.  Cold. — This  is  a  powerful  agent  in  arresting  malarial 
generation.  If  the  temperature  should  fall  below  the  freezing 
point,  only  for  one  night,  nothing  more  need  be  feared  in  that 
region  from  malaria,  until  the  average  temperature  shall  have 
again  reached  60°  F.  This  law  holds  in  all  malarial  districts. 
Malaria  is  most  active  from  June  till  November.  Malaria  is 
soluble  in  water,  and  Bartholow  found  the  surface  water  of  Kan- 
sas to  produce  malarial  fevers  and  cholera. 

Some  trees  and  plants  possess  the  property  of  absorbing  the 
malaria.  The  eucalyptus -tree  has  changed  the  nature  of  the 
malaria-breeding  portion  of  the  Algiers.  The  common  sun- 
flower, planted  in  moist  low-lands,  will  render  the  air  salubrious. 
All  ages  are  susceptible  to  malarial  poisoning;  and  all  races  are 
equally  so,  except  the  black.  Malarial  poison  may  gain  entrance 
into  the  human  body  through  the  respired  air,  or  through  food 
or  drink  (Bartholow  and  Loomis). 

Pathological  Anatomy. — The  changes  caused  by  malarial 
poisoning  are  essentially  the  same,  except  degree,  in  alb  forms  in 
which  the  disease  manifests  itself,  and  two  organs  (the  liver  and 
spleen)   are    chiefly  concerned.     In    acute    cases,    the   spleen  is 


INTERMIT TEXT  FEVER.  323 

much  enlarged.  In  some  chronic  cases  the  spleen  undergoes 
enormous  enlargement,  and  is  known  as  "ague-cake."  The  liver 
becomes  hypersemic  and  swollen.  The  1  train  is  also  hyperseniic 
(Bartholow). 

Symptoms. — Prodromal  stage. 

The  incubation  period  is  about  fourteen  days.  During  this 
time  there  are  symptoms  indicating  that  the  infection  is  working. 
These  are  called  prodromes.  The  patient  has  a  feeling  of  lassi- 
tude and  weariness,  backache  and  general  muscular  soreness;  he 
yawns  and  stretches,  has  headache,  coated  tongue  and  deranged 
stomach;  in  the  evening  his  skin  is  warm  and  dry,  but  he  has  pro- 
fuse sweat  in  the  morning.  There  may  be  yellow  sclerotic,  and 
a  general  yellowish  hue  of  the  skin,  loss  of  appetite  and  consti- 
pation.    The  urine  is  loaded  with  bile  pigment  (Bartholow). 

INTERMITTENT  FEVER, 

Called  also,  "fever  and  ague,"  "chill  fever,"  "the  shakes," 
"swamp  fever,"  "Panama  fever,"  is  characterized  by  the  occur- 
ence of  febrile  paroxysms  in  regular  succession,  and  by  the  ab- 
sence of  febrile  movement  between  the  paroxysms.  The  inter- 
mission is  the  distinctive  feature  of  this  form  of  fever,  as  its 
name  implies.  Like  typhoid  fever,  intermittent  fever  is  met 
with  in  all  parts  of  the  world,  except  in  the  extreme  north  or 
south. 

Morbid  Anatomy. — The  essential  anatomical  lesion  in  all 
forms  of  malarial  fever  is  the  presence  of  dark  pigment  in  the 
blood  and  in  certain  organs.  The  only  constant  pathological  le- 
sion of  intermittent  fever  is  congestion  of  the  internal  organs. 
The  spleen  and  liver  are  always  more  or  less  enlarged,  but  the 
enlargement  is  due  to  simple  hyperemia;  no  structural  changes 
occur  in  these  organs  until  the  intermittent  paroxysms  have  been 
often  repeated,  and  the  malarial  poisoning  has  been  of  long  dur- 
ation. There  is  also  more  or  less  hypersemia  of  the  kidneys  and 
mucous  membrane  of  the  intestine  (Flint  and  Loomis). 

Cause. — Malarial  poisoning  introduced  either  through  the 
lungs  or  intestinal  tract  (Loomis  ). 


324  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — Intermittent  fever  occurs  in  paroxysms.  There 
are  three  simple  types  of  this  fever.  The  first  and  most  common 
is  the  quotidian  type,  in  which  the  paroxysm  occurs  every  day, 
and  there  is  an  interval  of  24  hours  between  the  paroxysms. 
The  second  is  the  tertian  type,  in  which  the  paroxysm  occurs 
every  third  day,  with  an  interval  of  48  hours  between  the 
j)aroxysms.  The  third  is  the  quartan  type,  in  which  the  par- 
oxysm occurs  every  fourth  day,  with  an  interval  of  72  hours 
between  the  paroxysms.  There  are  other  types,  but  they  are 
only  modified  forms  of  those  already  mentioned,  such  as  double 
quotidian,  in  which  two  paroxysms  occur  daily.  Usually  one 
paroxysm  is  severe,  the  other  mild;  the  severe  one  generally 
occurs  in  the  morning,  the  milder  in  the  afternoon  or  evening. 
There  is  also  the  double  tertian,  in  which  a  paroxysm  occurs 
daily,  but  it  differs  from  quotidian  as  the  paroxysms  that  resem- 
ble each  other  occur  at  intervals  of  48  hours.  There  is  also  the 
double  quartan.  In  this  type  a  paroxysm  occurs  on  two  suc- 
cessive days,  and  on  the  third  day  there  is  no  paroxysm.  Cases 
have  been  observed  in  which  the  paroxysm  occurred  on  the  fifth, 
sixth,  seventh  and  eighth  day,  giving  us  a  quintan,  a  sextan,  a 
heptan,  and  an  octan  type  of  intermittent  fever.  The  types 
most  frequently  met  with  are  the  quotidian,  tertian  and  quartan. 
In  the  quotidian  t}^pe  the  paroxysm  occurs  in  the  morning,  in 
the  tertian  it  occurs  about  noon,  while  in  the  quartan  it  occurs 
in  the  afternoon  or  evening. 

Duration  of  Paroxysm. — In  the  quotidian  it  lasts  from 
eight  to  ten  hours,  in  tertian  it  lasts  from  six  to  eight  hours,  in 
quartan  from  four  to  six  hours. 

Description  of  a  Paroxysm. — Paroxysms  may  occur  at  any 
hour  of  the  day,  but  rarely  at  night.  A  paroxysm  consists  of 
three  stages — the  cold,  the  hot,  and  the  sweating  stage. 

Cold  Stage. — Pain  in  the  head,  a  sense  of  languor,  and  some 
nausea  usually  precede  this  stage.  %  When  the  cold  stage  comes 
on,  there  is  a  sensation  of  coldness  along  the  back,  which  soon 
extends  to  the  extremities,  and  gradually  creeps  over  the  whole 
body.  The  skin  becomes  shrivelled,  the  finger  ends  and  lips 
become  blue,  the  face  is  pale,  the  eyes  are  sunken,  chills  rapidly 
follow  each  other,  the  teeth  begin  to  rattle  together  and  the  bed 


INTERMITTENT    FEVER.  325 

shakes.  The  skin  assumes  the  appearance  of  goose-skin.  The 
temperature  rises  to  104°  or  105°  F.,  although  the  surface  of  the 
body  feels  cold.  The  pulse  is  small,  rapid,  and  the  tension  high. 
There  is  precordial  oppression  and  the  voice  is  weak  and  husky. 
The  respirations  are  rapid,  short  and  sighing.  The  urine  is  in- 
creased in  quantity  and  paler  than  normal,  and  there  is  a  frequent 
desire  to  empty  the  bladder.  There  is  extreme  thirst  and  often 
nausea  and  vomiting.  There  is  congestion  of  internal  organs. 
The  duration  of  this  stage  varies  from  a  half  hour  to  two  or 
three  hours.  Children  do  not  have  a  regular  chill;  they  merely 
grow  cold,  blue  and  livid. 

Hot  Stage. — The  skin  becomes  red,  hot  and  swollen,  and  the 
blood  recedes  from  the  internal  organs  to  the  surface.  There  is 
intense  pyrexia.  The  face  is  flushed  and  e}^es  red  and  fiery. 
The  juilse  grows  full,  rapid,  and  strong.  The  headache  con- 
tinues, but  the  pain  in  the  limbs  and  precordial  oppression  dis- 
appear.  The  temperature  marks  106°  or  107°  F.  Thirst  is 
intense.  Sometimes  herpetic  vesicles  appear  about  the  mouth. 
The  tongue  becomes  dry,  the  carotids  pulsate,  the  head  feels 
full;  there  are  noises  in  the  ears;  there  are  nausea  and  vomiting, 
and  there  may  be  excitement  and  delirium.  The  urine  in  this 
stage  becomes  scanty  and  high  colored.  The  duration  of  this 
stage  is  between  three  and  eight  hours  and  it  is  followed  by  the 
sweating  stage. 

Sweating  Stags. — The  sweat  appears  first  on  the  face  and 
then  on  the  trunk  and  extremities.  The  fever  gradually  abates 
and  at  length  disappears.  The  heat  of  the  surface,  cephalalgia, 
thirst,  restlessness,  etc.,  cease.  The  patient  obtains  refreshing 
sleep.  With  this  stage  the  paroxysm  ends.  The  average  dura- 
tion of  the  sweating  stage  is  three  or  four  hours.  As  a  rule,  the 
successive  paroxysms  recur  precisely  or  nearly  at  the  same  hour. 
When  the  paroxysm  comes  on  a  little  earlier  each  day,  it  is  called 
anticipating,  and  indicates  that  the  fever  is  not  being  controlled; 
when  it  comes  on  later  each  day,  it  then  indicates  that  the  fever 
is  being  controlled,  and  is  called  a  postponing  intermittent 
(Bartholow,  Flint  and  Loomis). 

Intermission. — The  intermission,  called  also  the  apyrexia] 
period,  is  the  space  of  time    between  two    successive    paroxysms. 


326  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

During  the  intermission  at  first  the  patient  may  feel  j)erfectly 
well,  but  if  the  disease  continue,  there  will  be  a  loss  of  vitality, 
he  becomes  pale  and  feeble  with  a  yellowish,  or  sallow  tint  to  the 
skin.  There  will  be  enlargement  of  the  spleen  and  liver,  and 
pigmentation  of  the  tissues.  These  characters  denote  what  is 
called  the  malarial  cachexia  (Loomis  and  Flint). 

Duration. — Of  the  disease  is  indefinite.  It  may  continue 
for  weeks  or  for  months.  The  liability  to  relapse  remains  for 
many  years. 

Dumb  Ague,  or  Latent  Intermittent  Fever. — When  the  chill 
and  sweat  are  absent,  but  a  sense  of  heat,  malaise,  headache  and 
lassitude  come  on  at  pretty  regular  periods  in  a  malarial  district, 
the  thermometer  showing  a  fever  of  102°  to  104°  F.  the  patient  is 
said  to  have  "dumb-ague"  (Loomis). 

Differential  Diagnosis. — Intermittent  fever  may  be  mistaken 
for  remittent  fever,  pyaemia,  and  pulmonary  phthisis.  In  remit- 
tent fever  there  is  never  a  complete  intermission,  whereas  in  in- 
termittent there  is  always  a  period  in  which  there  is  no  fever. 
In  remittent,  there  is  usually  but  one  chill,  while  in  intermittent 
a  chill  precedes  each  paroxysm  of  fever. 

Pyeemia  is  very  irregular  in  its  course,  no  defined  intervals 
occuring — intermittent  is  regular.  Pyeemia  is  due  to  wounds, 
suppuration  of  veins,  etc.,  intermittent  to  malaria.  The  former  is 
a  fatal  disease  over  which  quinia  has  no  influence,  the  latter  is 
promptly  cured  by  quinine.  Febrile  paroxysms  resembling 
those  of  intermittent  fever  are  sometimes  observed  in  connection 
with  pulmonary  phthisis.  They  may  present  the  three  stages 
well  marked,  and  recur  at  regular  intervals.  But  they  oftener 
occur  in  the  afternoon  than  in  the  forenoon,  whereas  the  reverse 
obtains  in  intermittent  fever  (Flint  and  Loomis). 

Treatment. — The  treatment  of  the  paroxysm  is  simply  to 
render  the  patient  comfortable.  The  patient  should  be  kept  in 
bed  during  the  paroxysm.  During  the  cold  stage,  cover  him  with 
blankets,  surround  him  with  bottles  of  hot  water  and  let  him 
drink  freely  of  hot  water.  During  the  hot  stage,  the  external 
heat  should  be  gradually  removed  and  cold  drinks  given.  If 
nausea  and  vomiting  are  present  give  opium  hypodermically. 
During  the  sweating  stage  let  him  alone.     The  treatment  for  the 


INTERMITTENT    FEVER.  327 

intermission  is  to  prevent  the  occurrence  of  another  paroxysm. 
A  patient  should  never  be  allowed  to  have  a  second  intermittent 
paroxysm.  The  sulphate  of  quinia  is  our  sheet  anchor  in  this 
disease,  and  it  is  all  powerful  if  skillfully  used.  At  least  thirty 
grains  of  quinine  should  be  administered  between  the  termina- 
tion of  one  paroxysm  and  the  hour  when  another  is  to  be  ex- 
pected. The  first  dose  of  ten  grains  should  be  given  toward  the 
close  of  the  sweating  stage,  and  twenty  grains  about  two  hours 
before  the  time  of  the  expected  paroxysm.  A  moderate  degree 
of  cinchonism  should  be  maintained  for  a  number  of  days. 
About  two  hours  before  the  time  of  day  at  which  the  first  par- 
oxysm occurred  from  ten  to  fifteen  grains  of  quinine  should  be 
daily  administered.  A  full  dose  of  opium  with  the  quinine  will 
sometimes  prevent  a  recurrence  of  the  paroxysm.  In  some 
chronic  forms  of  malaria,  arsenic  is  of  great  service.  Salicin, 
strychnia,  pipeline,  eucalyptus,  and  hydrastia  sometimes  act 
when  quinine  fails.  Flint  has  known  a  sinapism  applied  over 
the  whole  length  of  the  spine  at  the  beginning  of  the  cold  stage 
to  arrest  the  paroxysm  and  effect  a  cure.  A  full  opiate  at  the  be- 
ginning of  the  cold  stage  often  appears  to  shorten  and  modify  the 
severity  of  the  paroxysm.  For  the  treatment  of  the  enlarged 
spleen  there  is,  besides  the  exhibition  of  quinine,  no  remedy  more 
efficacious  than  the  ointment  of  the  red  iodide  of  mercury,  which 
is  rubbed  in  daily  over  the  splenic  region  in  the  sunshine,  until 
soreness  of  the  skin  compels  a  suspension  (Bartholow,  Loomis 
and  Flint). 

Prophylaxis. — Those  living  in,  or  going  to  malarial  regions, 
susceptible  to  the  action  of  the  poison,  must  avoid  all  excesses  of 
every  kind,  exposure  to  fatigue,  to  heat,  to  night  air,  and  should 
take  five  or  ten  grains  of  quinine  daily  in  the  morning,  in  some 
black  coffee,  to  procure  immunity  against  malarial  infection 
(Bartholow). 

PERNICIOUS  INTERMITTENT  FEVER. 

Called,  also,  malignant  congestive  or  tropical  typhoid  is  a 
severe  form  of  the  remittent  or  intermittent  fever.  It  occurs  in 
those  places  where  the  malaria  is  most  concentrated,  and  the 
malarial  fevers  most  severe. 


328  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Varieties. — There  are  several  varieties,  namely :  the  coma- 
tose, the  delirious,  the  algid,  the  icteric  and  the  gastro- enteric. 

Symptoms. — In  the  comatose  variety  during  the  hot  stage 
the  patient  passes  into  a  state  of  stupor  and  unconsciousness, 
lies  upon  his  back,  with  a  flushed  face,  congested  conjunctiva, 
dilated  pupils,  slow,  deep  and  stertorous  respiration.  He  some- 
times passes  into  a  condition  of  apparent  death  which  may  last 
for  hours.  If  the  patient  survive  the  first  and  second  paroxysms, 
he  usually  dies  during  the  third. 

In  the  delirious  variety,  the  patient  after  passing  into  the 
hot  stage,  becomes  wildly  delirious  and  requires  restraint.  This 
delirium  may  continue  for  hours.  These  attacks  of  delirium  may 
be  repeated  three  or  four  times  before  the  patient  dies. 

In  the  algid  variety,  after  the  patient  enters  the  hot  stage, 
the  surface  of  the  body  begins  to  grow  cold,  has  a  marble-like 
feel,  and  the  temperature  in  the  axilla  may  fall  to  88°  F.  or  84° 
F.,  while  the  rectal  may  range  from  104°  F.  to  107°  F.  The 
pulse  becomes  slower  and  slower,  falters,  and  disappears  at  the 
wrist.     The  patient  has  a  death-like  ajjpearance. 

In  tie  icteric  variety,  the  patient  has  a  violent  long- con- 
tinued chill,  during  which  jaundice  shows  itself.     The  jaundice 
gradually  deepens  and  extends  over  the  whole  body.     There  is 
•nausea  and  vomiting  of  bile.     The  temperature  reaches  106°  F. 
or  107°  F. 

In  tie  gastro  enteric  variety,  the  patient  after  passing  into 
the  hot  stage,  is  seized  with  almost  incessant  vomiting  and  purg- 
ing. The  discharges  are  stained  with  blood.  There  is  a  sense 
of  burning  in  the  stomach,  cramps  in  the  calves  of  the  legs,  cold- 
ness and  blueness  of  the  surface  and  sunken  eyes  (Loomis). 

Prognosis. — Unfavorable. 

Treatment. — Quinine  and  opiuin  are  the  only  reliable  agents 
for  this  disease.  From  five  to  seven  grains  of  quinine  should  be 
given  hypodermic-ally  every  hoar  until  the  paroxysm  has  jDassed 
away,  then  three  grain  doses  every  four  hours.  One-fourth  of  a 
grain  of  morphia  should  also  be  given  and  repeated  if  necessary. 
Warburg's  tincture  may  be  used  with  good  results.  A  half 
ounce  may  be  given  at  the  outset  of  the  paroxysm  and  this  dose 
repeated  if  necessary  (Loomis). 


REMITTENT     FEVER.  329 

REMITTENT  FEVER. 

Called  also  bilious  fever,  and  bilious  remittent  fever,  is  a 
form  of  malarial  fever  characterized  by  the  occurrence  of  re- 
missions instead  of  intermissions. 

Cause. — Malarial  poisoning. 

Symptoms. — There  are  oppression  in  the  epigastrium,  lassi- 
tude, nausea,  loss  of  appetite,  and  pain  in  the  limbs  and  head.  It 
does  not  come  on  gradually,  like  typhoid  fever,  but  abruptly, 
usually  with  a  chill.  The  chill  is  neither  so  complete,  nor  so 
long  continued  as  in  intermittent  fever  or  pneumonia.  There  is 
no  shaking  of  the  body  or  chattering  of  the  teeth.  Following 
the  chill  the  temperature  may  reach  105°  F.  or  106°  F.  The  face 
becomes  flushed,  the  eyes  congested,  and  there  is  vomiting  of  bile. 
The  febrile  symptoms  increase  in  severity  for  ten  or  twelve  hours, 
when  a  slight  moisture  appears  upon  the  surface,  and  the  tem- 
perature falls  one  or  two  degrees,  but  there  is  not  a  complete  in- 
terruption; the  fever  is  continuous.  At  the  same  hour  the  fol- 
lowing day  all  the  active  febrile  symptoms  return,  and  are  more 
severe.  This  rise  and  fall  of  temperature  constitutes  the  exacer- 
bation and  remission.  The  febrile  career  ends  during  the  second 
or  third  week.  It  eventuates  in  intermittent  fever  in  a  certain 
proportion  of  cases  (Loomis). 

Treatment. — Quinine  is  all  powerful  in  this  disease.  Loomis 
gives  ten  or  twenty  grains  of  quinine  at  a  dose  and  repeats  it 
every  two  hours  until  cinchonism  is  produced.  He  also  gives 
full  doses  of  bromide  of  potassium  to  promote  sleep.  Bartho- 
low  gives  thirty  grains  of  quinine  the  first  morning,  twenty  the 
second,  fifteen  the  third,  and  ten  the  fourth,  single  doses,  and  all 
taken  at  once. 

CONTINUED  MALARIAL  FEVER. 

Called  also  typho-malarial,  camp,  and  Chickahominy  fever 
is  an  association  of  typhoid  and  remittent  fevers.  Many  doubt 
the  existence  of  such  a  form  of  fever,  and  regard  the  so-called 
typhoid  element  as  nothing  more  than  a  typhoid  condition,  liable 
to  be  developed  in  connection  with  remittent  fever,  as  well  as 
with    many  other  diseases  (Loomis). 

Causes. — Are  malarial  poison,  and  some  other  poison.  It  is 
met   with  only  in  malarial    districts.     In   large   cities   in  which 


330  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

malarial  diseases  are  prevalent,  anti- hygienic  conditions,  such  as 
over -crowding  and  bad  sewerage,  seem  to  furnish  the  element  so 
essential  to  its  development  (Loomis). 

Symptoms. — There  are  usually  a  distinct  chill,  pains  in 
the  limbs  and  back,  headache,  loss  of  appetite  and  a  feeling  of 
great  exhaustion.  The  countenance  has  a  peculiar  waxy,  yel- 
lowish tinge.  There  may  be  nausea  and  vomiting,  abdominal 
tenderness  in  the  right  iliac  region  and  diarrhoea.  The  tongue 
has  first  a  white,  then  a  red,  and  then  a  brown  coating.  Sordes 
may  collect  upon  the  teeth  and  lips.  The  average  duration  of 
the  disease  is  three  or  four  weeks  (Loomis). 

Treatment.  —  When  the  malarial  element  predominates, 
quinine  and  Warburg's  tincture  are  the  best  remedies.  When 
the  typhoid  element  predominates,  give  the  regular  typhoid 
remedies. 

CHRONIC  MALARIAL  INFECTION. 

Or  malarial  cachexia,  may  be  a  sequel  of  any  form  of  acute 
malarial  disease.  It  may  develop  in  those  who  have  never  suf- 
fered from  any  form  of  malarial  fever,  but  who  have  resided  for 
some  time  in  a  malarial  district.  The  patient  becomes  anaemic 
with  enlarged  spleen  and  liver  (Loomis). 

Cause. — Malarial  poisoning. 

Symptoms. — Some  complain  of  vertigo,  ringing  in  the  ears, 
loss  of  memory,  disturbances  of  sight,  loss  of  appetite,  nausea 
dysj3etic  symptoms,  and  pain  and  oppression  in  the  epigastrium. 
Diarrhoea  is  often  present.  The  sleep  is  disturbed.  There  may 
be  pains  in  the  back  and  loins.  Some  become  easily  fatigued  on 
exertion,  have  shortness  of  breath  and  palpitation  of  the  heart. 
There  may  be  tingling  and  numbness  of  the  limbs.  Hemiplegia 
sometimes  occurs.  There  may  be  catarrhal  inflammation  of  the 
stomach,  intestine  and  bronchial  tubes.  Neuralgia  is  quite  com- 
mon in  this  affection  (Loomis). 

Treatment. — The  patient  should  be  removed  from  a  malari- 
ous district  to  a  high,  warm,  mountainous  region.  He  should 
wear  flannel  next  to  the  skin  and  avoid  exposure  to  wet  and  cold, 
and  the  damp  air  of  evenings  and  nights.  Quinine  must  be  given 
in  full  doses.     If  there  is  anaemia  iron  must  be  sdven.  The  iodide 


MALARIAL    FEVERS.  331 

of  iron  combined  with  cod  liver  oil  will  he  found  of  great  service. 
One-half  an  ounce  of  Warburg's  tincture  taken  daily  for  ten 
days,  two  hours  before  breakfast,  is  often  efficacious  when  qui  - 
nine  fails.  Aloes  or  rhubarb  should  be  given,  if  the  bowels  are 
constipated.  Arsenic  may  be  tried.  A  nutritious  diet  and  the 
daily  use  of  brandy  in  small  quantities  are  often  of  great  service 
(Loomis). 

PRESCRIPTIONS  FOR  MALARIAL  FEVERS. 

R     Quinire  sulphatis oiss. 

Acidi  sulphurici  dil 3ss. 

Spts.  setheris  nitrosi gss. 

Syrupi  tolutan. 

Aquse aa...q.  s — ad Siij- — M. 

Sig. :     A  teaspoonful  three  or  four  times  a  day.  — DaCosta. 

R     Chinoidini gr.  xL. 

Resinse  podophylli gr.  iv. 

Ferri  sulpb  exsic    gr.  xx. — M. 

Ft.  massa  et  in  pil.  no.  xx.  div. 
Sig.:     One  three  times  daily.  — Bartholow. 

R     Tincturae  iodi 3vj. 

Potassii  iodidi 3ij- 

Aquas  cinnamonii  ad  siij. — M. 

Sig.:     A  teaspoonful  three  times  daily.  — Charity  Hospital. 

R     Acidi  carbolici gj. 

Tincturae  iodi  comp 3 i i j . — M. 

Sig.:     Four  drops  every  four  hours  well  diluted.       — Bartholow. 

R     Quininaj  sulphatis gr.  xvj. 

Ext.  glycyrrhizas 5j. 

Syr.  rubri  idsei Sij. — M. 

Sig.:     A  teaspoonful  three  to  five  times   daily  for   a    child  three 
years  old.  — J.  Lewis  Smith. 

R     Pulveris  opii gr.  xij . 

Pulveris  capsici gr.  xxxvi. 

Quininte  sulphatis 5j. — M. 

In  pulveres  no.  xii.  div. 
Sig.:     One  powder  three  times  daily.  — Alonzo  Clark. 


332  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

MASTITIS.     (See  Inflammation  of  Breast). 
PRESCRIPTIONS  FOR  MASTITIS. 

R     Ammonii  carbonatis Sj. 

Aquse  Oj.—  M. 

Sig.;     Apply  locally.  —Starr. 

R     Cerati  resinse  comp gj. 

Olei  olivee  3J-ij- — M. 

Ft.  ungt. 
Sig..     Apply,  spread  generously  on  soft  linen.     (When  suppura- 
tion is  threatened).  — Witherstine. 

R     Lini  farini  

Aquas bullientis aa q.s... 

Ft.  cataplasm  a. 
Sig. :     Apply  as  hot  as  can  be  borne.  — Witherstine. 

R     Linimenti  camphorse Sviij. — M. 

Sig. :     Apply    locally,    rubbing    gently   from    the   circumference 
toward  the  nipple.     (In  incipient  mastitis.)  — Parry. 

R     Atropine  sulphatis  gr.  viij. 

Aqua?  rosse oij. — M. 

Ft.  lotio. 
Sig.:     Apply  locally,  but  discontinue  in    case   of    dilatation    of 
pupils,  or  dryness  of  throat.  — Starr. 

MANIA.     (Acute  and  Chronic.) 

Maniacal  conditions  are  so  familiar  and  so  readily  recognized 
that  they  need  not  be  described  here.  There  are  mainly  two 
disorders  with  which  acute  mania  is  liable  to  be  confounded, 
namely — acute  meningitis  and  delirium  tremens. 

In  acute  meningitis,  there  are  severe  headache,  drowsiness, 
tingling  and  numbness  in  the  extremities,  tense  pulse,  decided 
fever,  etc.  In  acute  mania,  the  patient  has  little  if  any  fever,  no 
spasms;  his  pupils  are  not  contracted;  his  stomach  is  not  irrita- 
ble, and  has  no  headache. 

In  delirium  tremens,  he  is  talkative  and  restless,  has  a  moist 
skin,  compressible  pulse,  and  creamy  tongue.  In  acute  mania 
these  conditions  do  not  prevail  (DaCosta). 


MANIA MARASMUS— MEASLES.  333 

PRESCRIPTIONS  FOR  MANIA. 

|fc     Potassii  bromidi §j. 

Tinct.  cannabis  indica? 5j. 

Syru pi  sim plicis §ij . 

Aquae q.  s.,  ad ,iiv. — M. 

Sig. :     A  tablespoonful  thrice  daily.  — Clouston. 

JJr     Hyoscyamite  sulphatis gr.  j. 

Aqua?  destillataa ,5xij . — M. 

Sig.:     Five  to  twelve  minims  hypodermically. 

MARASMUS. 

Is  a  general  wasting,  emaciation,  or  atrophy.  There  are 
many  constitutional  diseases  which  produce  a  condition  known  as 
marasmus.  The  following  prescriptions  are  useful  in  this  con- 
dition : 

{fc     Tinct.  cinchonse  comp 

Tinct.  gentina?  comp aa §j. — M. 

Sig. :     Fifteen  drops  to  a  teaspoonful  in  sweetened  water,  thrice 
daily.  J.  Lewis  Smith. 

Jfc     Syr.  ferri  iodidi  ^j. 

Sig. :     Three  to  five  drops  in  water  thrice  daily  after  eating. 

— Eustace  Smith. 

Jfc     Olei   morrhute oij- 

Aqua?  calcis 5iv. 

Syr.  calcis  lactophosphites...ad...siv. — M. 
Sig.:     A  teaspoonful  two  or  three  times  daily.  — Bosley. 

MEASLES. 

Called  also  rubeola  and  morbilli,  is  an  eruptive  fever,  with 
catarrhal  symptoms  referable  to  the  broncho-pulmonary  mucous 
membrane,  self-limited  and  terminating  in  about  two  weeks 
(Bartholow).  Measles  is  a  disease  from  which  few  persons  es- 
cape. It  is  essentially  a  disease  of  childhood,  but  it  may  occur 
at  any  age.  A  second  attack  is  of  rare  occurrence.  It  is  char- 
acterized by  an  eruption  of  red  spots:   It  is  contagious  (Loomis). 

Causes. — Measles  appears  in  alljmrts  of  the  globe.  The  dis- 
ease may  be  communicated  not  only  by  contact  with  the  sick. 
but  the  morbific  principle  adheres  to  articles  of  clothing  by  which 


334  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

it  may  be  conveyed  long  distances,  or  in  other  words  it  is  a  port- 
able disease.  Measles  prevails  as  an  epidemic,  and  in  the  spor- 
adic form.  All  are  not  alike  susceptible.  Infants  at  the  breast 
are  not  liable.  The  disease  prevails  mostly  in  the  fall,  winter  and 
spring.  The  duration  of  the  period  of  incubation  varies  from 
one  to  thirty  days;  the  average  being  ten  days  (Bartholow  and 
Loomis). 

Symptoms. — The  course  of  this  disease  is  definite  and  is  di- 
vided into  the  stages  of  invasion,  eruption  and  desquamation. 

Stage  of  Invasion. — At  the  end  of  the  period  of  incubation, 
the  patient  begins  to  sutler  from  cough,  fever,  anorexia,  thirst, 
chills,  a  feeling  of  weariness,  muscular  soreness,  headache  and 
backache.  There  is  an  acrid  muco- serous  discharge  from  the 
nostrils.  The  eyes  are  irritable,  reddened  and  watery,  and  have 
a  brilliant  appearance.  The  buccal  and  faucial  surfaces  are  in- 
jected. Sore  throat  is  complained  of,  and  the  voice  is  a  little 
husky.  The  bronchitis,  laryngitis  and  coryza  which  accompany 
this  disease  are  due  to  the  efflorescence  which  takes  place  on  the 
mucous  membrane  of  the  air- passages  prior  to  its  appearance  on 
the  skin.  There  may  be  nausea  and  vomiting.  The  face  is 
flushed  and  somewhat  swollen.  Epistaxis  is  frequent.  The 
average  duration  of  the  stage  of  invasion  is  three  or  four  days. 
It  may,  however,  be  a  single  day  or  seven  days;  then  the  erup- 
tion appears  (Flint,  Smith  and  Loomis). 

Stage  of  Eruption. — The  eruption  is  first  seen  upon  the 
forehead,  chin  and  sides  of  the  nose,  then  upon  the  neck,  chest 
and  over  the  body,  afterwards  upon  the  legs  and  arms,  and  lastly 
upon  the  back  of  the  hand.  The  eruption  on  the  face  feels  like 
small  shot  early  in  the  disease.  The  eruption  fully  develops  in 
36  to  48  hours,  and  then  begins  to  fade.  Convulsions  may 
occur  in  this  stage.  The  eruption  has  at  first  an  appearance  of 
minute  red  clots  and  specks  which  soon  enlarge  to  the  size  of  a 
pin-head  or  to  three  pin-heads;  they  disappear  upon  pressure 
and  return  when  the  pressure  is  removed.  These  spots  are 
usually  discrete  and  separated  by  tracts  of  normal  skin.  The 
eruption  is  sometimes  attended  with  considerable  itching.  The 
efflorescence  may  be  seen  on  the  hard  and  soft  palate  one  or  two 
days  before  it  appears  on  the  face.     In  this  stage  the  constitu- 


MEASLES.  335 

tional  and  local  symptoms  increase  in  severity.  The  face  is 
swollen,  the  eyes  still  watery  and  sensitive  to  light;  the  tongue 
is  covered  with  a  moist  thin  fur,  and  its  papillae  are  prominent, 
though  less  so  than  in  scarlet  fever.  The  cough  continues,  the 
appetite  is  lost,  and  thirst  is  intense.  A  severe  form  of  the  dis- 
ease is  characterized  by  the  occurrence  of  petechia  and  hemorr- 
hage in  various  situations.  In  these  cases  the  eruption  presents 
a  livid  appearance,  and  is  called  hemorrhagic  rubeola,  or  rubeola 
nigri  or  black  measles.  Some  writers  describe  measles  without 
catarrh,  and  on  the  other  hand  with  catarrh,  but  without  the 
rash.  On  the  fourth  day  of  the  eruption  it  begins  to  fade,  and 
the  stage  of  desquamation  commences  (Flint,  Smith,  Loomis  and 
Bartholow). 

Stage  of  Desquamation. — The  duration  of  this  stage  is  be- 
tween four  and  eight  days.  It  is  characterized  by  a  scanty  fur- 
furaceous  exfoliation  of  the  epidermis.  In  this  stage  all  the 
symptoms  rapidly  abate,  but  the  cough  continues  several  days 
(J.  Lewis  Smith). 

Complications. — The  most  important  complications  are 
bronchitis,  capillary  bronchitis,  broncho -pneumonia,  meningitis, 
ophthalmia,  otorrhcea,  entero- colitis,  eclampsia,  diphtheria,  and 
acute  tuberculosis.     Nephritis  is  a  rare  complication  (Smith). 

Prognosis. — Is  always  good  in  uncomplicated  cases,  but  the 
various  complications  render  the  prognosis  unfavorable  (Smith). 

Treatment. — Uncomplicated  cases  require  little  medical 
treatment.  The  child  should  be  kept  in  an  airy  room  at  a  uni- 
form temperature  of  about  70°  F.  The  diet  should  be  mild  and 
for  the  most  part  liquid.  Stimulation  by  wine  or  brandy  may 
be  necessary.  For  the  troublesome  cough,  flaxseed  tea  or  infus- 
ion of  slippery  elm  bark,  with  lemon  juice  added  may  be  given. 
A  small  Dover's  powder  is  good  for  the  cough.  The  chest  should 
be  covered  with  cotton  wadding,  after  rubbing  on  camphorated 
oil.  If  the  patient  complains  of  itching  and  burning  of  the  sur- 
face, he  may  be  frequently  sponged  with  tepid  water.  If  there 
is  thirst,  cold  water  may  be  freely  taken  in  small  quantities  at  a 
time.  Inhalations  of  steam  are  most  useful  for  the  lung  compli- 
cations. In  capillary  bronchitis  and  pneumonia  the  following 
prescription  is  most  serviceable  : 


336  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

R     Arnmonii  carbonat gr.  xvj.  ^ss. 

Aquas  pura? 5ij- — M. 

Sig. :  Give  one  teaspoonful  in  three  or  four  of  milk  every  hour 
or  two.  The  chloride  of  ammonium  is  also  good  in  double  the  dose  of 
carbonate  (Smith).  If  the  temperature  is  high  during  the  initial 
stage,  and  the  cough  troublesome,  the  following  is  most  effective  : 

|&     Tinct.  aconit.  rad 3j. 

Ext.  ipecac  fid oij- 

Tinct.  opii  deodorat siij. — M. 

Sig. :     Six  drops  every  hour  or  two.  — Bartholow. 

During  the  time  of  the  eruption,  if  the  temperature  is  high 
the  skin  should  be  rubbed  every  four  hours  with  lard,  suet,  vase- 
line or  cocoa- butter.  A  simple  saline  laxative  ought  to  be 
given.  Quinine  may  be  used  to  reduce  the  fever  (Bartholow 
Loomis  and  Smith). 

MELANCHOLIA. 

Is  a  form  of  insanity  characterized  by  a  condition  of  mental 
depression.     Melancholiacs  have  gloomy  visages. 

Causes. — Diseases  of  the  brain,  anaemia,  and  physical  pros- 
tration. 

Symptoms. — The  patient  is  dreadfully  depressed  and  his  ex- 
pression is  completely  altered.  He  suffers  from  no  appreciable 
disease.  Usually  he  gazes  toward  the  ground.  The  tendency  of 
the  melancholic  is  frequently  to  suicide. 

Treatment. — It  is  necessary  to  isolate  melancholic  patients 
from  their  friends  and  relatives.  The  use  of  opium  in  the  form 
of  the  tincture,  in  gradually  increasing  doses,  is  productive  of 
the  best  results.  A  prolonged  warm  bath  (one-half  to  two  hours) 
is  a  good  hypnotic  agent  in  melancholia.  Frequent  feeding  is 
of  the  greatest  importance  (Starr).  The  bromide  of  potassium 
is  most  serviceable  for  the  unendurable  despondency  (Einger). 

PRESCRIPTIONS  FOR  MELANCHOLIA. 

|fc     Quinke  valerianatis : 

Ferri  valerian  atis , 

Zinci  valerianatis— aa gr.  xx. — M. 

Ft.  massa  et  in  pil.  no.  xx.  div. 
Sig.:     One  pill  three  times  daily.  — Witberstine. 


MENINGITIS.  337 

|fc     Potassii  bromidi ..--Sij- 

Tinct.  calumba giij. 

Spts.  ammonias  aromat gij. 

Aqua?  cinnamoni giij . 

Aquas q.  s.,  ad sviij. — M. 

Sig. :     A  wineglassful  two  or  three  times  daily.  — Lawrence. 

jfc     Tinct.  ferri  chloridi 

Syr.  simplicis — aa ,$j . — M. 

Sig. :     Twenty  drops  well  diluted  thrice  daily.  — Bartholow. 

MENINGITIS. 

Inflammation  of  the  pia  mater  is  usually  called  meningitis. 
The  term  pachymeningitis  is  applied  to  inflammation  of  the  dura 
mater  (Loomis).  Sometimes  inflammation  of  the  pia  mater  is 
denominated  le}3tomeningitis.  It  may  be  acute  or  chronic. 
Acute  cerebral  meningitis  is  also  called  simple  meningitis  of  the 
convexity,  cerebral  fever,  and  arachnitis. 

Causes. — Acute  alcoholismus,  prolonged  and  intense  mental 
anxiety  and  grief  are  among  its  predisposing  causes.  Injuries  of 
the  cranial  bones,  as  fractures,  severe  blows,  or  punctured  wounds 
are  the  most  frequent  exciting  causes.  Diabetes,  cerebral  tumors, 
disease  of  the  cranial  bones,  suppuration  of  the  middle  ear,  and 
eyeball,  and  large  carbuncles  about  the  cranium  have  caused  it. 
Meningitis  may  occur  as  a  complication,  in  measles,  small -pox, 
scarlet  fever,  ulcerative  endocarditis,  Bright's  disease,  acute 
pneumonia,  typhus,  typhoid  fever,  diphtheria,  pyaemia,  and  rheu- 
matism. Long  continued  exposure  to  intense  heat  of  the  sun 
may  cause  it.  It  is  more  common  in  males  than  in  females.  It 
is  most  frequent  in  early  adult  life  and  in  young  children  (Flint 
and  Loomis). 

Symptoms. — May  be  divided  into  three  stages  of  headache, 
delirium,  and  coma.  It  may  be  ushered  in  by  a  distinct  chill  or 
chilly  sensations.  The  first  prominent  symptom,  as  a  rule,  is  a 
violent  headache.  With  the  headache  there  is  vertigo,  intense 
photophobia,  loud  ringings  in  the  ears,  nausea,  and  projectile 
vomiting.  The  face  is  flushed,  and  has  an  anxious  expression. 
The  conjunctiva  are  injected,  and  the  pupils  are  contracted.  The 
bowels  are  constipated  and  the  abdomen  is  retracted.     The  fever 


338  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  more  or  less  intense,  and  the  pulse  is  accelerated,  strong  and 
full.  The  carotids  and  temperal  arteries  jDulsate  strongly,  and 
the  head  is  hot.     The  duration  of  this  stage  is  one  or  two  days. 

In  the  second  or  stage  of  delirium,  there  are  great  restless- 
ness and  mental  confusion.  The  delirium  is  sometimes  wild, 
simulating  acute  mania.  In  adults,  muscular  twitchings  of  the 
face  and  extremities  are  present  in  this  stage;  the  eyeballs  roll 
about  vaguely,  the  flexor-muscles  are  often  powerfully  contracted 
in  one  or  both  limbs,  and  there  may  be  opisthotonos.  The  tem- 
perature rises  to  104°  F.,  the  pulse  becomes  more  frequent  and  ir- 
regular; the  abdomen  is  retracted,  the  vomiting  continues  pro- 
jectile. Herpetic  eruptions  appear.  This  stage  lasts  from  one 
to  three  days. 

The  third  stage  is  called  the  stage  of  coma.  It  comes  on 
gradually.  The  delirium  and  headache  subside.  There  is  a  ten- 
dency to  stupor  and  deep  sleep.  The  pulse  becomes  slow,  irreg- 
ular and  intermittent.  The  pupils  are  greatly  dilated.  There 
is  rigidity  of  the  muscles  of  the  back  of  the  neck.  Strabismus 
and  loss  of  vision  may  occur.  The  patient  rolls  his  head  and 
grinds  his  teeth  and  picks  stupidly  at  the  bedclothes.  Gradually 
the  coma  becomes  profound.  Subsultus  tendinum  is  marked. 
As  the  disease  advances,  the  pulse  may  run  up  to  160  or  170 
or  more;  the  Cheyne-Stokes  respiration  of  ascending  and  descend- 
ing rhythm  becomes  established.  The  expirations  are  puffing. 
The  body  is  bathed  in  cold  sweat  (Flint  and  Loomis). 

Differential  Diagnosis. — Acute  meningitis  may  be  confounded 
with  cerebral  hypersemia,  acute  uraemia,  variola  and  delirium  tre- 
mens. From  cerebral  hypersemia,  meningitis  is  differentiated  by 
the  higher  temperature,  longer  duration,  and  the  symptoms  of 
depression  succeeding  to  a  stage  of  excitement.  In  uraemia  the 
temperature  is  usually  below  rather  than  above  the  normal;  the 
urine  is  scanty  and  contains  albumen,  and  there  is  or  has  been 
dropsy.  In  small-pox,  the  face  is  flushed,  the  pulse  full  and 
bounding,  there  is  intense  pain  in  the  back  and  loins,  the  vomit- 
ing is  retching  in  character,  and  at  the  end  of  the  third  day  the 
characteristic  eruption  appears.  In  delirium  tremens,  the  patient 
imagines  persons  and  animals  about  him,  and  is  wild  in  his  ges- 
tures   and  utterances.     The  surface    is    bathed    in    a  profuse, 


MENINGITIS.  339 

clammy  sweat  in  delirium  tremens;  it  is  hot  and  dry  in  meningitis. 
In  delirium  tremens  the  temperature,  pulse  rate,  and  pupils  are 
normal,  and  there  is  no  headache  (Bartholow  and  Loomis). 

Prognosis. — Is  very  unfavorable.  The  duration  varies  from 
two  days  to  four  weeks;  fatal  cases  rarely  last  more  than  eight 
days.  Strabismus,  hiccough  and  local  paralysis  are  very  unfavor- 
able symptoms. 

Treatment. — The  head  should  be  raised;  the  room  dark  and 
quiet.  The  ice-bag  should  be  put  to  the  head.  Leeches  may  be 
applied  to  the  nape  of  the  neck  and  mastoid  bone.  The  bowels 
should  be  moved  freely.  Blisters  may  be  applied  to  the  back  of 
the  neck.  Bartholow  recommends  during  the  stage  of  excita- 
tion, tincture  of  aconite  (two  dro]3s)  every  two  hours.  He  also 
gives  bromide  of  potassium  (5ss.)  and  fluid  extract  of  ergot  (5ss.) 
every  four  hours.  Iodide  of  potassium  in  five  to  ten  grain  doses 
four  or  five  times  daily  may  be  given. 

PRESCRIPTIONS  FOR  ACUTE  CEREBRAL  MENINGITIS. 

R     Acidi  tannici  5j. 

In  capsulas  no.  xx.  div. 
Sig. :     A  capsule  every  three  hours,  with  ice  to  head.     — Lardier. 

R     Sodii  bromidi 5ij 

Chloral  hydratis 5j  • 

Syr.  auranti  cort gj. 

Aquse q.  s.,  ad giij. — M. 

Sig  :     A    dessertspoonful    every  hour   or   two    until    excitement 
abates.  — Herrrnan. 

R     Tincturse  ferri  chloridi 5j. 

Sig. :     Twenty  to  thirty  minims  every  two  hours.  — Klapp. 

Chronic  Cerebral  Meningitis. — Is  an  interstitial  inflamma- 
tion of  the  pia  mater  which  causes  thickening  and  opacity  of  the 
membrane  (Loomis). 

Causes. — It  is  a  disease  of  adult  life,  especially  after  fifty 
years  of  age.  It  may  be  a  combination  of  chronic  alcoholismus, 
syphilis,  rheumatism,  gout  and  chronic  Bright's  disease  (Loomis). 

Symptoms. — Are  obscure.  The  patient  grows  dull,  stupid 
and  apathetic.    There  is  headache  and  a  constant  desire  to  sleep. 


340  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Vomiting  occurs.     There  is  muscular  weakness,  vertigo  and  tin- 
nitus aurium  (Looniis). 

Treatment. — The  patient  must  be  kept  quiet  mentally,  and 
the  diet  must  be  fluid  and  nutritious.  The  bichloride  of  mercury 
and  iodide  of  potassium  are  considered  the  best  remedies.  The 
bowels  and  urine  need  careful  attention  (Loomis). 

Tubercular  Meningitis. — Called  also  basilar  meningitis,  is 
an  inflammation  of  the  basal  pia  mater  caused  by  gray  miliary 
tubercles  and  occurring  most  frequently  in  children  (Loomis). 

Causes. — It  is  rare  before  the  first  and  after  the  fifth  year. 
It  occurs  most  frequently  in  scrofulous  children.  Any  debili- 
tating disease  may  excite  it.  The  immediate  cause  is  the  same 
as  in  all  forms  of  tuberculosis  (Loomis). 

Symptoms. — There  is  loss  of  appetite;  the  breath  is  offen- 
sive; the  tongue  coated,  constipation  and  diarrhoea  alternate. 
The  child  becomes  dull,  languid,  and  desires  quiet.  The  face 
has  an  anxious  appearance.  There  may  be  convulsions.  In  the 
first,  or  irritative  stage,  the  patient  will  moan  and  clasp  the  head 
with  his  hands.  He  awakes  with  a  piercing  hydrocephalic  cry, 
grinds  his  teeth,  rolls  his  eyeballs,  and  the  facial  muscles  are 
contorted.  The  hands  will  be  clenched.  The  abdomen  is  re- 
tracted and  hard.  Projectile  vomiting  occurs,  and  resists  all 
treatment.  The  pupils  are  contracted,  there  is  photophobia.  In 
the  second,  or  stage  of  depression,  the  muscles  at  the  back  of  the 
neck  become  rigid;  the  head  is  rolled  slowly  from  side  to  side; 
sometimes  distinct  opisthotonos  occurs.  The  pulse  becomes 
slow;  convulsions,  ptosis,  strabismus,  loss  of  sight,  anaesthesia 
and  local  paralysis  may  occur.  There  is  difficult  swallowing. 
Cheyne- Stokes'  respiration  is  common.  There  is  anorexia,  the 
tongue  and  mouth  are  covered  with  sordes;  and  the  passages  are 
unnatural  and  offensive.  In  the  third,  or  stage  of  coma,  the 
pulse  runs  up  to  150  or  170  per  minute,  is  feeble,  small  and 
irregular.  The  pupils  are  widely  dilated.  The  breathing  is 
sighing  or  snoring  in  character.  Dysphagia  is  marked.  The 
contents  of  the  bladder  and  rectum  are  passed  involuntarily;  the 
body  is  covered  with  a  clammy  sweat.  The  abdomen  becomes 
tympanitic  and  subsultus  tendinum  is  marked  (Loomis). 


MENINGITIS.  341 

Differential  Diagnosis. — Tubercular  meningitis  may  be  mis- 
taken for  acute  meningitis,  gastro- enteritis,  acute  Bright's  dis- 
ease and  infantile  remittent  fever. 

Acute  meningitis  is  sudden  in  its  onset  and  rapid  in  its  pro- 
gress, not  so  in  tubercular.  The  ocular  symptoms  and  the  boat- 
shaped  abdomen  are  more  prominent  in  the  tubercular  than  in 
other  forms  of  meningitis.  In  gastro- enteritis,  there  are  diar- 
rhoea, abdominal  pain  and  tenderness.  But  headache,  contracted 
pupils,  photophobia,  the  slow  irregular  pulse,  reflex  movements 
during  sleep,  projectile  vomiting  and  the  hydrocephalic  cry  of 
tubercular  meningitis  are  wanting. 

In  Bright's  disease,  the  oedema,  with  the  presence  of  albu- 
men and  casts  in  the  urine,  will  establish  the  diagnosis.  In 
infantile  remittent  the  vomiting  is  retching  in  character,  diarrhoea 
is  prominent,  and  the  discharges  pea- soup  in  character,  the 
abdomen  is  distended  and  tender;  there  is  great  thirst,  rapid 
pulse  and  normal  pupils  (Loomis). 

Prognosis. — It  is  one  of  the  most  fatal  diseases  of  childhood. 
The  duration  varies  from  five  days  to  four  weeks  (Loomis). 

Treatment. — The  prophylactic  treatment  is  cod-liver  oil,  and 
the  patient  kept  out  of  doors  as  much  as  possible,  also  good 
hygienic  surroundings.  The  treatment  is  symptomatic  after  the 
disease  is  developed.  The  bowels  must  be  kept  open,  and  abso- 
lute quiet  enjoined.  Ice-bags  may  be  put  to  the  head.  Opium 
and  bromide  of  potassium  are  serviceable  in  the  stage  of  excite- 
ment (Loomis). 

PACHYMENINGITIS. 

Is  an  inflammation  of  the  dura  mater.  There  are  two 
forms,  namely  :     Pachymeningitis,  externa  and  interna. 

Causes. — Pachymeningitis  externa  is  caused  by  injury  and 
disease  of  the  cranial  bones,  by  sujopuration  of  the  internal  or 
middle  ear,  or  of  the  orbit.  The  causes  of  the  internal  form  are 
chronic  alcoholismus,  pyaemia  and  Bright's  disease.  It  is  rare 
before  forty,  most  frequently  between  sixty  and  eighty  (Loomis). 

Symptoms. — Somnolence,  headache,  dizziness,  photophobia, 
followed  by  delirium,  and  perhaps  convulsions  and  coma,  are  the 


342  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

chief  symptoms.     The  course  of  the  disease  varies  from  one  day 
to  a  year  or  more  (Flint). 

Treatment. — For  the  external  form,  rest,  a  mild  diet,  a  free 
purge,  and  cold  to  the  head  are  indicated.  Trephining  may 
sometimes  save  life.  If  there  are  symptoms  of  suppuration  alco- 
holic stimulants,  quinine,  and  opium  should  be  given.  The  ex- 
ternal form  must  be  treated  symptomatically.  The  prognosis  is 
unfavorable  in  both  forms  (Loomis). 

SPINAL  MENINGITIS. 

Is  an  inflammation  of  the  spinal  pia  mater  and  arachnoid. 
It  may  be  acute  or  chronic. 

Causes. — Acute  spinal  meningitis  may  be  caused  by  a  fall, 
blow,  dislocation,  fracture  or  other  injury  to  the  vertebrae,  or 
concussion;  by  any  disease  of  the  spine,  such  as  caries,  cancer, 
prolonged  exposure  to  cold — especially  damp  cold — or  brief  ex- 
posure to  intense  cold  when  the  body  is  heated,  as  well  as  ex- 
posure to  intense  heat.  Operations  for  spina  bifida  have  been 
followed  by  rapid  and  fatal  spinal  meningitis.  Syphilis,  venereal 
excesses,  alcoholismus,  chorea,  tetanus,  and  hydrophobia  may 
cause  it. 

The  chronic  form  may  follow  the  acute  (Loomis). 

Symptoms. — More  or  less  pain  is  felt  in  the  spine  radiating 
therefrom  to  the  extremities.  The  pain  is  increased  by  move- 
ments of  the  body  and  is  constant.  The  surface  of  the  body  be- 
comes hypersesthetic,  and  the  reflexes  are  increased.  There  may 
be  a  chill,  nausea,  vomiting,  fever,  and  the  muscles  along  the 
spine  become  rigid.  There  is  constipation,  and  the  abdomen  has 
the  well  known  boat  shaped  appearance.  The  duration  of  this 
disease  is  seven  to  ten  days.  The  majority  of  cases  are  fatal 
(Flint). 

Treatment. — The  indications  for  treatment  are  the  same  as  in 
acute  cerebral  meningitis.  The  patient  should  be  put  to  bed  in 
a  cool  room  and  a  brisk  purge  administered.  Ice  or  counter  irri- 
tation may  be  applied  along  the  spine.  Ergot  and  belladonna 
are  said  to  produce  contraction  of  the  arterioles,  and  retain  the 
inflammatory  process. 


MENINGITIS MYELITIS.  343 

When  the  symptoms  denote  the  presence  of  the  products  of 
inflammation,  vesication  of  the  spine  and  iodide  of  potassium  in 
large  doses  are  indicated.  Warm  baths  are  grateful  to  patients 
(Flint  and  Loomis). 

The  different  varieties  of  meningeal  inflammation  and  the 
terms  applied  to  each  may  be  made  clearer  by  the  following 
definitions : 

1.  By  the  term  meningitis  is  usually  understood  inflamma- 
tion of  the  pia  mater  or  of  the  pia  mater  and  arachnoid. 

2.  By  the  term  leptomeningitis  is  meant  inflammation  of 
the  pia  mater,  or  of  the  pia  mater  and  arachnoid  of  the  non- tu- 
bercular variety. 

3  By  the  term  simple  cerebral  meningitis  is  understood  in- 
flammation of  the  pia  mater  either  of  the  convexity  or  of  the  base 
of  the  non -tubercular  variety. 

4.  By  the  term  tubercular  meningitis  is  meant  an  inflam- 
mation of  the  basal  pia  mater  caused  by  tubercle  bacilli. 

5.  By  the  term  pachymeningitis  is  meant  inflammation  of 
the  dura  mater. 

The  same  terms  are  applied  to  spinal  meningeal  inflam- 
mation. 

MYELITIS. 

Is  an  inflammation  of  the  substance  of  the  spinal  cord.  It 
may  be  acute  or  chronic. 

Forms. — When  the  inflammation  occurs  chiefly  in  the  central 
gray  matter,  it  is  called  central  myelitis;  when  the  white  matter 
and  meninges  are  involved  it  is  called  cortical  myelitis;  when 
both  white  and  gray  matter  of  the  greater  portion  of  the  cord 
are  inflamed  the  process  is  called  diffuse  myelitis;  when  the  in- 
flammation is  confined  to  the  anterior-horns  of  gray  matter,  it  is 
called  anterior  polio -myelitis;  when  all  the  tissues  of  the  cord 
over  a  circumscribed  space  are  involved  it  is  called  transverse 
myelitis;  when  there  are  spots  of  inflammation  along  the  cord  at 
various  points  it  is  called  disseminated  myelitis.  Acute  myelitis 
in  the  majority  of  cases,  appears  under  the  form  of  softening  of 
the  cord.  Chronic  myelitis,  on  the  other  hand  appears  as  indu- 
rated or  sclerosis  (Flint). 


34:4:  A    COMPENDIUM    OF    PEACTICAL     MEDICIXE. 

Acute  MyeUHs. — Causes. — Acute  myelitis  is  a  rare  disease. 
It  is  more  common  in  males  than  in  females.  It  is  a  disease  of 
children  and  young  adults.  In  children  it  takes  the  form  of 
acute  anterior  polio-myelitis  or  spinal  paralysis.  Injuries  of  the 
cord  from  contusions,  blows,  fractures  of  the  vertebra,  intense 
and  prolonged  muscular  action,  prolonged  exposure  to  cold,  as  in 
sleeping  on  damp  ground,  sudden  chilling  of  the  surface  when 
overheated  and  excesses  in  coitus  are  given  as  causes.  It  is  said 
that  suppression  of  the  menses  and  checking  hemorrhoidal  fluxes 
may  cause  it.  Acute  infectious  disease  may  give  rise  to  myelitis. 
Continued  jarring  of  the  spine  from  travel  on  railways  will 
produce  it  (Bartholow,  Loomis  and  Flint). 

Symptoms. — Acute  myelitis  usually  begins  with  fever,  intense 
pain  in  the  back,  the  sensation  of  a  girdle  around  the  trunk,  ten- 
derness over  certain  of  the  vertebra?,  pains  and  muscular  soreness 
of  the  limbs,  tingling,  formication,  a  feeling  of  weight  and  drag- 
ging in  the  rectum  and  bladder,  and  priapism.  Preceding  paralysis, 
the  muscles  which  are  to  be  paralyzed  are  sometimes  affected 
with  tremor  or  spasm.  The  early  occurrence  of  paralysis  is  a 
distinguishing  feature.  It  occurs  within  a  day  or  two,  and  some- 
times within  a  few  hours  after  the  symptoms  have  jDointed  to  a 
spinal  affection.  The  paralysis  is  mostly  paraplegic,  affecting 
both  bladder  and  rectum,  is  motor  and  sensory,  and  may  develop 
so  rapidly  that  in  48  hours  the  patient  will  be  unable  to  move 
his  legs.  Loss  of  reflex  excitability  is  an  effect  of  destruction  of 
the  gray  matter  in  the  lower  part  of  the  cord.  Xotable  wasting 
of  the  paralyzed  muscles  is  indicative  of  destruction  of  the  gray 
matter.  In  myelitis,  the  parts  exposed  to  pressure  take  on  gan- 
grenous inflammation.  Acute  myelitis  is  a  progressive  disease, 
and  may  run  a  rapid  course,  destroying  life  in  a  few  days  or 
weeks.  Complete  recovery  is  rare  (Bartholow,  Loomis  and 
Flint). 

Differential  Diagnosis. — Acute  myelitis  may  be  confounded 
with  acute  spinal  meningitis.  In  meningitis,  there  are  acute  pain 
on  motion,  rigidity,  sj3asnis  and  contractions  of  the  muscles  of 
the  back,  hyperesthesia,  and  incomplete  paralysis;  in  myelitis, 
there  is  no  pain  on  motion,  the  muscles  are  flaccid  and  relaxed, 


MYELITIS.  345 

there  are  anaesthesia  and  paraplegia,  or  hemiplegia  (Loomis  and 
Bartholow). 

Prognosis. — In  acute  myelitis  death  may  occur  in  twelve  to 
thirty  hours,  or  be  delayed  two  or  three  weeks  (Loomis). 

Treatment. — Absolute  rest  must  be  enjoined.  Frequent 
applications  of  hot  water  to  the  spine  is  very  serviceable.  The 
ice-bag  to  the  spine  is  recommended.  Bartholow  recommends  a 
mustard  plaster  the  length  of  the  spine  and  four  inches  wide,  to 
be  applied  twice  daily.  Dry  cupping  over  the  spine  and  leeches 
are  indicated.  Internally  ergot  and  belladonna  have  been  highly 
recommended.  Authorities  recommend  a  tablespoonful  four 
times  daily  of  the  infusion  of  digitalis.  Twenty  to  thirty  grain 
doses  of  quinine  may  have  a  good  effect  at  the  very  beginning 
of  the  congestive  stage.  Purgatives  should  be  given.  Bed-sores 
must  be  prevented.  Cystitis  may  be  avoided  by  the  frequent 
use  of  the  catheter  and  washing  out  of  the  bladder  (Bartholow, 
Loomis  and  Flint). 

CHRONIC  MYELITIS. 

Causes. — Are  much  the  same  as  those  of  acute  myelitis. 

Symptoms. — Pains  in  the  limbs  simulating  rheumatism,  mus- 
cular weakness,  tingling,  formication,  numbness  of  the  limbs, 
and  a  girdle  sensation  are  the  first  symptoms.  These  are  fol- 
lowed by  paraplegia,  muscular  atrophy,  cystitis  and  chronic  bed- 
sores. Patients  with  chronic  myelitis  always  contain  of  cold 
feet. 

Prognosis. — Always  unfavorable.  It  may  continue  from  two 
to  ten  years  (Loomis). 

Treatment.— The  treatment  for  the  acute  will  be  of  service 
in  the  chronic  form. 

Chronic  Myelitis  includes  several  distinct  affections,  among 
which  are  posterior  spinal  sclerosis  (which  has  been  considered 
under  the  name  of  locomotor  ataxia),  multiple  cerebro- spinal 
sclerosis,  sclerosis  of  the  lateral  columns,  anterior  polio-myelitis, 
and  progressive  muscular  atrophy. 


346  A    COMPENDIUM    OF    PRACTICAL     MEDICLTSTE. 

MULTIPLE  CEREBRO=SPINAL  SCLEROSIS. 

Is  a  malady  characterized  "by  the  formation  of  isolated 
patches  or  nodules  of  sclerotic  tissue  in  the  brain,  pons,  medulla, 
cerebellum,  and  spinal  cord  (Bartholow).  The  nodules  vary  in 
number  and  range  in  size  from  minute  objects  to  the  size  of  a 
walnut  (Loomis). 

Causes. — It  is  very  rare  after  the  age  of  forty-five  and  be- 
fore ten.  Heredity  is  a  predisposing  cause.  The  exciting  causes 
are  damp  and  cold,  sudden  chilling  of  the  body,  traumatism, 
and  severe  and  long- continued  brain  work  or  physical  exercise. 
Moral  emotions,  chagrin,  anxiety,  and  continued  jarring  of  the 
body  are  thought  to  produce  the  disease  (Bartholow  and 
Loomis). 

Symptoms. — The  disease  may  come  on  gradually  or  sud- 
denly. If  it  appears  gradually,  the  patient  complains  of  head- 
ache, vertigo,  muscular  weakness,  mental  disturbance,  and  queer 
feelings,  as  formications,  itchings,  burnings,  etc.,  in  the  limbs. 
There  may  be  nausea  and  vomiting.  There  is  a  loss  of  co-ordi- 
nating power,  and  the  patient  cannot  control  his  hands  in  writing, 
or  his  feet  and  limbs  in  walking.  There  is  a  shaking  tremor; 
this  tremor  is  peculiar  in  not  occurring  until  an  attempt  is  made 
at  voluntary  motions,  and  at  once  ceasing  when  the  parts  are 
allowed  to  rest.  Even  the  head  participates  in  it.  The  voice  is 
changed,  and  the  patient  talks  in  a  low  monotone  or  a  whisper, 
dividing  the  words  as  in  scanning  a  line  of  poetry.  Amblyopia, 
diplopia,  nystagmus,  and  inequality  of  the  pupils  are  frequent 
symptoms.  In  the  advanced  stage,  vesical  symptoms,  acute  bed 
sores,  loss  of  sexual  power  and  control  of  the  sphincter  become 
marked  symptoms. 

Differential  Diagnosis. — Cerebro- spinal  sclerosis  may  be  mis- 
taken for  paralysis  agitans  or  locomotor  ataxia.  In  paralysis 
agitans  the  fine  tremor  exists  when  the  patient  is  at  rest,  and  is 
not  accompanied  by  shaking  of  the  head;  while  in  the  shaking 
of  the  cerebro -spinal  sclerosis  the  head  is  always  involved,  the 
symptom  ceasing  as  soon  as  the  patient  is  at  rest.  The  former  is 
rare  before  forty;  the  latter  is  rare  after  forty.  Changes  in  the 
voice  and  speech  and  ocular   symptoms   are  present  in  cerebro- 


SCLEROSIS.  347 

spinal  sclerosis,  and  absent  in  paralysis  agitans.  In  locomotor 
ataxia  the  peculiar  shaking  tremor,  impairment  of  voice  and 
speech,  and  nystagmus  that  belong  to  disseminated  sclerosis  are 
absent.  In  the  former  there  are  the  girdle  sensation  about  the 
trunk,  the  lightning-like  pains  and  the  peculiar  double  beat  in 
walking,  all  of  which  are  absent  in  the  latter  (Loomis  and  Bar- 
tholow). 

Prognosis. — The  disease  is  progressive  and  always  terminates 
in  death.  The  duration  varies  from  one  year  to  twenty,  but  the 
average  is  five  to  ten  years.  The  patient  is  apt  to  die  from 
an  intercurrent  disease  (Bartholow  and  Loomis  ). 

Treatment. — Various  remedies  have  been  proposed  for  this 
malady.  Erb  gave  arsenic  hypodermically  in  one  case  with  ini- 
jnovernent.  Hammond  thinks  the  chloride  of  barium  does  good. 
According  to  Bartholow  the  chloride  of  gold  and  sodium,  with 
small  doses  of  corrosive  sublimate,  is  most  useful.  Cod-liver  oil, 
nitrate  of  silver,  phosphate  of  zinc  and  galvanism  have  all  been 
used  by  authorities. 

LATERAL  SPINAL  SCLEROSIS. 

Called  also  by  Charcot,  spasmodic  tabes  dorsal  is,  and  by 
Erb  spastic  spinal  paralysis,  is  a  disease  having  similar  lesions  to 
those  of  posterior  spinal  sclerosis,  but  a  different  seat.  The 
site  of  the  lesions  is  the  lateral  white  columns,  and  the  changes 
consist  in  gray  degeneration. 

Causes. — It  develops  under  the  same  conditions  as  posterior 
spinal  sclerosis.  It  is  more  common  in  men  than  in  women,  and 
occurs  between  the  ages  of  twenty  and  fifty.  Traumatism  and 
exposure  to  wet  and  cold  are  given  as  causes  (Loomis). 

Symptoms. — There  will  appear  first  weakness  and  paresis  of 
the  lower  extremities;  then  twitching;  of  the  muscles  and  muscu- 
lar  rigidity  follow.  The  tendon  reflexes  in  this  disease  are  much 
exaggerated.  The  sensibility  is  unaffected;  there  is  no  atrophy 
of  the  muscles;  and  the  functions  of  the  rectum,  bladder  and 
sexual  system  remain  unaltered.  There  is  marked  ankle  clonus, 
in  which  the  muscles  of  the  calf  or  the  whole  limb  are  put  in  a 
state  of  tremor  when  the  foot  is  fiexed,  or  when  the  patient  j)uts 


348  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

his  toes  to  the  ground.  The  patient  drags  his  limbs.  The  dura- 
tion of  the  disease  extends  over  many  years  (Bartholow,  Loomis 
and  Flint). 

Treatment. — The  galvanic  current  is  most  useful.  Iodide  of 
rjotassiuni,  arsenic  and  cod -liver  oil,  with  careful  attention  to 
rest  and  diet,  are  to  be  recommended.  Rubbing  and  massage 
afford  great  comfort.  Calabar  bean  may  be  given  for  the  cramps 
(Loomis). 

ANTERIOR  POLIOMYELITIS. 

Called  also  infantile  spinal  paralysis,  is  a  disease  occurring 
in  children  suddenly,  and  is  due  to  an  inflammation  of  the  an- 
terior cornua  of  gray  matter  of  the  cord.  It  may,  however,  occur 
in  adults,  but  much  less  frequently  (Bartholow). 

Causes. — This  is  a  disease  of  the  first  three  years  of  life. 
Cold,  dentition  and  traumatism  have  been  assigned  as  causes.  It 
is  frequently  developed  during  convalescence  from  the  exanthe- 
mata and  other  acute  febrile  affections  (Loomis). 

Symptoms. — The  usual  onset  of  the  disease  is  a  fever  which 
lasts  a  day  or  two,  and  on  recovery  from  which  it  is  observed, 
with  surprise,  that  the  child  is  paralyzed.  There  maybe  head- 
ache, pain  in  the  back,  and  limbs,  nausea,  vomiting,  vertigo,  de- 
lirium, convulsions  and  coma.  In  some  cases  the  paralysis 
occurs  without  prodromes.  If  only  one  lower  limb  is  involved 
at  first,  the  other  soon  becomes  so,  and  it  is  not  unusual  for  all 
four  extremities  to  be  affected  at  once.  Sensibility  is  not  affected. 
The  bladder  may  be  paralyzed,  and  the  urine  retained.  Paralysis 
is  complete  at  once,  and  soon  begins  to  lessen,  some  restoration 
of  power  taking  place  in  from  one  to  three  weeks.  All  the 
jDaralyzed  parts  maybe  restored,  or  one  arm  and  one  leg  may  re- 
main paralyzed.  The  muscles  remaining  paralyzed  are  affected 
permanently,  and  by  a  rapidly  progressive  atrophy.  The  para- 
lyzed parts  become  cool,  to  the  touch,  and  have  a  blue  cyanosecl 
apjDearance.  The  muscles  waste  till  there  is  nothing  but  con- 
nective tissue  and  fat,  and  the  growth  of  the  limb  is  arrested. 
The  mildest  cases  recover  in  a  few  weeks  or  in  a  mouth  or  two 
(Bartholow). 


MUSCULAR    ATROPHY.  349 

Treatment. — From  \  to  4  grains  of  quinine  and  from  -fa  to  £■ 
grain  of  belladonna  extract  have  acted  best  according  to  Bar- 
tholow.  Hot  douche  to  the  spine,  galvanism,  and  rest,  with 
massage  and  faradism  are  of  service.  Strychnia  may  be  injected 
into  the  paralyzed  parts  two  or  three  times  a  week.  Tonics  are 
clearly  indicated  (Bartholow). 

PROGRESSIVE  MUSCULAR  ATROPHY. 

Called  also  wasting  or  creeping  palsy,  is  a  disease  charac- 
terized by  a  progressive  and  chronic  wasting  and  atrophy  of  the 
voluntary  muscles  due  to  atrophic  changes  in  the  anterior  cornua 
of  the  cord  (Loomis). 

Causes. — It  is  an  hereditary  disease,  and  is  met  with  chiefly 
in  males.  The  period  of  greater  liability  is  between  the  ages  of 
thirty  and  fifty.  The  disease  may  be  excited  by  over- exertion  of 
a  group  of  muscles  in  certain  occupations.  Injury  to  the  spine 
and  exposure  to  cold  and  wet  are  said  to  excite  it.  In  children 
the  disease  is  invited  to  the  lower  limbs  by  prolonged  effort  on 
the  legs.  Exhausting  diseases,  the  poison  of  lead  and  syphilis, 
and  certain  dyscrasise  seem  to  exert  an  influence  in  developing 
the  disease  (Bartholow  and  Loomis). 

Symptoms. — The  disease  usually  comes  on  insidiously,  the 
first  indication  of  its  presence  being  wasting  and  loss  of  power 
of  some  muscles;  as  a  rule  those  of  the  hand  are  first  atrophied, 
then  the  muscles  of  the  forearms,  arms  and  shoulders.  Just 
l»ef ore  wasting  begins,  the  j)atient  will  remember  that  he  had 
for  weeks  or  months  a  feeling  of  slight  numbness  or  formication, 
and  that  his  fingers  have  seemed  clumsy.  The  patient  complains 
of  a  sensation  of  cold  air  being  blown  on  him.  Wandering  pains 
frequently  precede  the  wasting  of  the  muscles.  A  peculiar 
fibrillary  tremor  is  present  early  (Loomis). 

Prognosis. — Is  extremely  unfavorable.  Its  course  is  slow. 
The  average  duration  is  five  years.  As  its  name  implies,  it  is 
always  progressive  (Loomis). 

Treatment.— Bartholow  recommends  injections  of  a  solution 
of  ^  glycerine  three  times  a  week  into  the  wasting  muscles.  A 
descending  current  of  galvanism  should  be  ajyplied  to  the  whole 


350  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

length  of  the  spine  daily,  for  two  minutes.  Massage,  using  with 
friction  lard,  should  consist  of  friction,  kneading  and  tapping 
the  muscles.  Hot  douches  to  the  spine  and  rubbing  a  wet  pack 
over  the  affected  members  are  also  highly  to  be  commended. 

MENORRHAGIA  AND  METRORRHAGIA. 

Menorrhagia  is  an  increased  flow  of  the  blood  and  mucus 
occurring  at  the  menstrual  period. 

Metrorrhagia  is  a  flow  of  blood  from  the  genitalia  in  the 
inter -menstrual  period. 

Causes. — May  be  general  or  local.  The  general  causes  are 
hemorrhagic  diathesis,  scurvy,  fevers,  tuberculosis,  super-lacta- 
tion, icterus,  Bright's  disease,  obesity  and  cachexia.  The  local 
causes  are  reflex  stimulus  from  the  genital  organs  or  simply  from 
nervous  derangement,  as  at  puberty,  first  intercourse  or  the 
menopause.  Reflex  stimulation  from  the  mammary  glands  during 
lactation  will  cause  metrorrhagia.  Other  local  causes  are  endo- 
metritis, fibromata,  cancer,  ovarian  tumors,  and  affections  of  the 
Fallopian  tubes  (Pozzi). 

Treatment. — The  cause  should  always  be  sought  and  treated. 
The  local  measures  are  prolonged  irrigation  of  hot  water  (110° 
to  120°  F.)  and  tampon  of  the  vagina.  Astringents,  such  as 
tincture  of  iodine  with  glycerine  or  Monsel  solution  diluted,  may 
be  applied  to  the  endometrium.  The  general  measures  are:  Rest 
in  bed  with  elevation  of  the  pelvis;  opium  in  the  form  of  lauda- 
num, rectal  injections;  ergot  by  the  stomach  and  infusion  of 
digitalis  leaves.  In  many  cases  fluid  extract  of  hydrastis  given 
in  half- drachm  doses  every  four  hours  during  the  time  of  the 
flow,  and  in  twenty- drop  doses  before  meals  in  the  intervals,  is 
very  efficient.  Oil  of  erigeron  in  five-minim  capsules  every  three 
hours  is  also  effective  (Pozzi). 

PRESCRIPTIONS  FOR  MENORRHAGIA. 

R     Extracti  ergotae  fluidi XHx. 

Ammonii  chloridi gr.  x. 

Sodii  bromidi  gr.  v. — M. 

Sig. :     For  one  dose,  to  be  taken  in  half  tumbler  of  water  ;    may 
repeat  every  two  hours.  — Goodell. 


MENORRHAGIA MORNING    SICKNESS.  351 

R     Ext.  gossypii  fid 

Syr.  simplicis  aa §j. — M. 

Sig. :     A  teaspoonful  every  four  hours.  — Parvin. 

R     Ext.  rhois  aromat  fid §iv. 

Sig. :     A  teaspoonful  every  hour  for  a  few  doses,  then  every  three 
or  four  hours.  — Shoemaker, 

R     Acidi  gallici 3ss. 

Acidi  sulphurici  dil 3j. 

Tinct  opii  deodorat gj. 

Inf.  rosse  comp Siv. — M. 

Sig.:     A  tablespoonful,  every  four  hours.  — Bartholow. 

R     Tinct  hamamelis §ij. 

Sig. :     One-half  to  one  teaspoonful  thrice  daily.  — Ringer. 

R     Ext.  ipecac  fid gij. 

Ext.  ergotse  fid giv. 

Ext.  digitalis  fid gij. — M. 

Sig.:     A  half  to  one  teaspoonful  as  required  until  emesis  occurs. 

— Bartholow. 
R     Potassii  bromidi gij. 

In  pulv.  no.  xii.  div 

Sig.:     A  powder  in  a  wineglassful  of  water  three  times  daily.  (In 

flooding  of  young  women  who  menstruate  too  often  as  well  as  too 

copiously).     Begin  before  the  period  and  continue  till  it  is  over. 

— Ringer. 
R     Tinct.  sabinse , . .  Sss . 

Sig. :     Five  to  ten  drops  in  cold  water  every  half  to  three  hours. 

—Phillips. 
MIGRAINE.     (See  Headache). 

MITRAL  DISEASE.     (See  Valvular  Diseases). 

MORNING  SICKNESS. 

The  nausea  and  vomiting  which  occur  in  pregnant  women 
on  waking  in  the  morning  are  called  morning  sickness. 

It  is  due  to  spasmodic  contractions  of  the  diaphragm  and 
stomach.  It  usually  recurs  daily  during  the  first  three  months 
of  pregnancy  and  then  gradually  disappears  (Lusk). 

Treatment, — Nearly  every  drug  of  the  Materia  Medica  has 
been  tried  at  one  time  or  another  for  the  nausea  and  vomiting  of 
pregnancy.  Spraying  the  pit  of  the  stomach  with  ether  is  effect- 
ive in   some  cases.     To  many,  ice-cold  effervescent   drinks  are 


352  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

grateful.  Lusk  orders  ten  grains  of  the  subnitrate  of  bismuth 
combined  with  five  to  ten  grains  of  oxalate  of  cerium  to  be  taken 
ten  minutes  before  eating.  He  also  gives  ten  drop  doses  before 
meals  of  the  tincture  of  mix  vomica  in  cases  of  gastric  catarrh. 
Drop  doses  of  Fowler's  solution  at  meal- time  are  said  to  exert 
considerable  influence  in  allaying  stomach  irritability.  After 
eating,  digestion  may  be  promoted  by  ten  grains  of  pepsin  given 
alone  or  with  dilute  muriatic  acid.  If  the  vomiting  is  literally 
uncontrollable,  the  patient  should  be  placed  at  rest  in  bed 
(Lusk). 

PRESCRIPTIONS  FOR  MORNING  SICKNESS. 

Jlr     Cocaini  muriatis gr.  j. 

Extracti  belladonna? 3 vi. — M. 

Sig. :     Apply  locally  to  the  cervix  uteri  morning  and  evening. 

— Fenn. 

JJr     Cocaini  muriatis gr.  j. 

Aqua?. §j . — M. 

Sig.:     A  teaspoonful  three  times  daily  before  meals.       — Parvin. 

{&     Atropia  sulphatis gr-j- 

Morphia?  sulphatis .gr.  iv. 

Acidi  sulphurici  aromat .giij- 

Aqua? 3v. — M. 

Sig. :     Ten  to  twenty  drops  in  water  thrice  daily.  — Boys. 

Jfc     Cerii  oxalatis gr.  xxiv. 

Extracti  hyoscyami gr.  xxxvj. — M. 

Ft.  massa  et  in  pil.  no.  xii.  div. 
Sig.:     One  pill  twice  daily.  — Goodell. 

MUMPS. 

Called  also  parotitis,  or  parotiditis,  is  a  constitutional  or 
blood  disease  with  local  manifestations.  It  is  a  specific  inflam- 
mation of  the  parotid  gland  (rarely  are  the  other  salivary  glands 
involved),  self-limited,  and  characterized  by  a  tendency  to  mi- 
grate into  the  mamma  or  testes.  Parotitis  is  of  two  varieties, 
specific  and  non-specific  (Smith  and  Bartholow). 

Causes. — It  occurs  chiefly  in  childhood,  youth,  and  early 
manhood,  cases  being  rare  in  infancy  and  old  age.     It  is  highly 


mumps.  353 

contagious,  and  commonly  occurs  as  an  epidemic.  It  prevails 
most  in  crowded  localities  and  among  those  who  live  in  cold 
damp  cellars.  It  is  probably  a  microbic  disease  (Smith  and 
Loomis). 

Incubation. — The  period  of  incubation  varies  from  ten  to 
eighteen  days  (Flint).* 

Symptoms. — Mumps  begins  wtih  languor  and  fever,  and 
usually  chills  or  chilly  sensations.  There  are  frequently  dull 
pains  in  the  limbs,  loss  of  appetite,  headache  and  delirium.  In 
36  to  48  hours,  there  is  a  sensation  of  stiffness  about  the  angle 
of  the  jaw,  followed  by  pain  and  swelling.  The  pain  is  in- 
creased by  speaking,  swallowing  and  by  pressure.  The  disease 
reaches  its  height  in  from  three  to  five  days,  and  the  swelling  of 
the  gland  begins  to  subside  on  the  seventh  or  eighth  day.  A 
metastatic  orchitis  may  occur  in  males  after  puberty.  In  females, 
the  mammary  gland  and  ovary  may  become  inflamed.  It  is  one 
of  the  diseases  which  affect  the  same  person  but  once.  Non- 
specific parotitis  developing  during  some  severe  constitutional 
disease,  shows  a  tendency  to  suppurate  from  its  beginning,  and 
discharges  laudable  pus  (Bartholow,  Flint,  Loomis  and  Smith). 

Prognosis. — Is  favorable  in  the  specific  variety;  but  very  un- 
favorable in  the  non-specific  (Loomis). 

Treatment. — Warm  applications  to  the  affected  parts  will 
give  relief.  Morphine  and  quinine  may  be  given  internally.  A 
mild  saline  cathartic  may  be  administered.  The  diet  should  be 
non- stimulating.  Inunctions  of  oil  to  the  swollen  gland  are 
useful.  A  mustard  foot-bath  should  be  given  (Bartholow  and 
Loomis). 

PRESCRIPTIONS  FOR  MUMPS, 

|fc     Antipyrine  5j. 

Potassii  bromidi 5 iij . — M. 

In  pulvus  no.  xv.  div. 
Sig. :     Grfe  one  powder  in  water  every  three  hours  till  the  fever 
abates.  — J.  Lewis  Smith. 

Jji     Hydrargyri  cum  cretas gr.  iv. 

Saceharri  lactis gr.  xx. — M. 

In  pulvus  no.  xii.  div. 
Sig.:     One  powder  three  or  four  times  daily.  — Ringer. 


354  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

MYALGIA. 

Called  also  muscular  rheumatism,  is  a  rheumatic  affection 
of  the  voluntary  muscles  accompanied  by  pain  and  tenderness, 
but  by  no  other  evidences  of  inflammation.  It  has  been  named 
according  to  its  seat,  torticollis  (wry-neck),  cephalalgia,  pleuro- 
dynia, lumbago,  etc.  (Loomis). 

Causes. — Exposure  to  cold  and  damp  draughts  are  often  the 
exciting  causes  of  an  attack.  Over-fatigue  and  sudden  straining 
of  a  muscle  may  induce  it.  Malaria  may  cause  it.  It  may  come 
on  suddenly  in  a  rheumatic  or  gouty  subject  (Loomis). 

Symptoms. — An  attack  usually  comes  on  suddenly  with 
severe,  deep-seated  pain  in  the  muscles  affected.  The  pain  is  of 
a  stretching  or  tearing  character,  increased  by  movement  or  pres- 
sure. It  is  more  severe  at  night.  The  pain  may  shift  or  remain 
fixed  in  certain  muscles.  Certain  positions  mitigate  the  pain. 
Lumbago  is  the  severest  variety.  In  all  varieties  there  is  pain 
and  rigidity  of  muscles,  but  no  fever  or  constitutional  symptoms. 
The  duration  of  myalgia  varies  between  a  few  hours  and  a 
week.     The  duration  of  the  chronic  form  is  indefinite  (Loomis). 

Treatment. — In  the  young,  cod-liver  oil  acts  as  a  preventive. 
A  hot  air  or  Turkish  bath  will  be  of  service  at  the  beginning  of 
an  attack.  In  chronic  cases  the  favorite  drugs  are  arsenic,  sul- 
phur, and  guaiacum.  Quinine  is  almost  a  specific  in  the  malarial 
form.  The  patient  should  wear  flannel  and  sponge  the  body 
with  cold  water  every  morning. 

In  lumbago  hot  applications  and  anodyne  liniments  will 
often  give  relief.  A  hypodermic  of  morphia  may  be  required. 
The  constant  and  faradic  currents  may  give  relief  (Loomis). 

MANIA=A=POTU.     (See  Delirium  Tremens.) 

MASTURBATION. 

Called  also  self- abuse  or  self- pollution,  is  not  a  disease.  It 
signifies  that  an  orgasm  is  produced  by  means  of  friction  with 
the  hand.  It  does  not  necessarily  produce  disease  unless  it  is 
carried  to  excess.  Masturbation  is  not  confined  to  man. 
Monkeys,  bears  and  goats  indulge   in   it.     Turkeys   practice   it 


MASTURBATION.  355 

upon  a  round,  smooth  stone.  In  the  human  being,  both  sexes 
practice  it.  Females  are  much  less  given  to  it  than  males.  The 
majority  of  women  have  very  little  passion,  and  suffer  the  ap- 
proaches of  a  lover  or  husband  largely  as  a  matter  of  complais- 
ance. As  a  rule,  the  female  learns  what  passion  is  only  as  the 
result  of  education  after  marriage.  With  the  male  it  is  different. 
He  often  has  erections  in  childhood  and  sexual  yearnings  long 
before  puberty.  A  boy,  when  handling  himself  during  erec- 
tion, is  apt  to  find  the  sensation  agreeable  and  go  on  until  he 
has  formed  the  habit.  Male  babies  are  sometimes  handled  by 
their  nurses  to  keep  them  quiet,  and  this  begets  the  habit.  Boys 
usually  receive  instruction  from  other  boys  at  school,  and  this  is 
the  most  common  incentive.  A  large  proportion  of  mankind 
have  masturbated  more  or  less  at  some  jjeriod  of  life,  and  it  is 
safe  to  assert  that  at  least  ninety  per  cent,  of  such  masturbators 
are  not  injured  by  the  habit.  Sexual  indulgence  in  the  natural 
way  will  produce  evil  effects  if  carried  to  excess,  yet  it  is  proba- 
ble that  sexual  intercourse  is  not  only  harmless,  but  even  bene- 
ficial in  moderation.  It  is  not  the  loss  of  seminal  fluid  which  is 
of  the  first  importance  in  producing  disease  from  sexual  excess, 
but  the  nervous  shock  of  the  oft-repeated  orgasm. 

Babies  and  young  children  lose  no  seminal  fluid,  women 
have  none  to  lose,  yet  in  all  these,  evil  results  follow  excesses,  as 
certainly  as  they  do  in  the  male  after  puberty. 

Any  succession  of  nervous  shocks  as  sharp  and  decisive  as 
the  sexual  orgasm,  such  as  joy  or  fear,  would  shatter  the  vitality 
and  nervous  tone  of  an  individual  as  much  as  masturbation.  The 
cunningly  conceived  advertisements  in  newsjDapers,  books  and 
circulars  by  quacks,  implant  errors  in  the  mind  concerning  this 
vice  which  years  of  sober  after  thought  are  scarcely  able  to  erad- 
icate. Masturbation  is  not  confined  to  youth;  middle  and  old 
age  are  not  free  from  it.  The  use  of  tobacco  and  alcohol  in- 
flicts as  much  injury  upon  the  human  race  as  does  the  secret 
vice,  if  both  are  carried  to  excess. 

The  chief  reason  why  so  much  is  said  of  venereal  excess  by 
masturbation,  and  so  little  of  sexual  excess  in  the  natural  way, 
is,  that  the  former  is  so  much  more  common  and  not  that  the  act 
itself  is  physically  more  harmful.     The  former  may  be  practised 


356  A    COMPEiSTDIUIVI    OF    PRACTICAL     MEDICIXE. 

on  all  occasions,  even  in  company,  by  the  hand  in  the  pocket,  in 
bed  or  in  solitary  places,  bnt  the  latter  requires  the  consent  of 
two  individuals,  and  opportunities  which  relatively  are  hard  to 
find  (Keyes). 

Symptoms, — A  young  child  who  masturbates,  has  many 
erections,  and  handles  his  genitals  frequently.  Such  children  are 
fretful,  peevish,  thin,  nervous,  excitable  and  sleep .  badly.  Boys 
who  masturbate  usually  have  a  long  prepuce ;  they  have  a  sallow 
look,  and  sheepish,  hang- dog  expression.  They  are  melancholy, 
sit  by  themselves,  become  absent  minded,  and  the  innocent  frank- 
ness of  youth  is  absent.  The  young  man  is  over  shy,  unambi- 
tious, he  shrinks  from  a  steady  gaze,  blushes  readily,  and  seems 
conscious  of  having  done  something  unmanly  and  little.  Men 
who  masturbate  often  show  no  sisni  of  the  habit,  and  it  is  rare 
for  them  to  practice  it  to  excess.  In  the  vast  majority  of  in- 
stances, masturbation  does  little  harm  to  the  individual  except 
in  regard  to  his  morals.     The  practice  is  a  base  one  (Keyes). 

Treatment. — If  a  nurse  handles  an  infant  she  should  be  dis- 
charged. If  the  infant  has  already  acquired  the  habit  his  hands 
must  be  tied  when  he  sleeps,  and  at  other  times  watched. 
Boys  should  always  be  made  to  sleep  alone.  The  best  treatment 
is  to  elevate  the  boy  out  of  his  bad  habit,  to  shame  him,  to  make 
a  man  out  of  him,  to  sympathize  with  him,  and  to  treat  him 
morally.  When  a  man  comes  complaining  of  the  results  of  mas- 
turbation, it  will  be  found  that  he  is  a  hypochondriac,  and  his 
malady  ungratified  sexual  desire.  He  should  be  encouraged  and 
advised  to  marry.  Medicines  are  of  little  or  no  value.  Cold- 
sponge  baths,  out- door  sports,  physical  fatigue,  sleeping  in  a  cold 
room  on  a  hard  bed,  with  light  covering,  eating  lightly  at  night, 
and  not  retiring  until  very  sleepy  are  all  useful  in  breaking  up 
the  habit  (Keyes). 


MOLES MILIUM.  857 

MILK=LEG.     (See  Phlegmasia  Alba  Dolens.) 

MISCARRIAGE.     (See  Abortion.) 

MENIERE'S  DISEASE.     (See  Vertigo.) 

MOLES. 

Are  very  common,  few  people  being  without  one  or  more 
upon  the  surface  of  the  body,  while  many  have  them  in  numbers. 
Moles  are  sometimes  congenital,  constituting  one  of  the  varieties 
of  "  mother's  marks,"  and  sometimes  acquired.  They  occur  in 
the  shape  of  circumscribed  brown  patches,  and  on  the  face  in  the 
gentler  sex  are  often  regarded  as  beauty  spots.  They  are  rarely 
of  any  great  importance  beyond  the  disfigurement  they  produce. 
Occasionally  they  become  the  seat  of  a  cancerous  disease;  the 
melanotic  sarcoma  has  frequently  its  origin  in-  such  congenital 
spots.  Many  of  the  most  virulent  forms  of  multiple  cancer  the 
surgeon  sees  have  their  origin  in  moles  (Bryant). 

Treatment. — The  surgeon  should  excise  any  mole  that  has  a 
tendency  to  grow  or  become  indurated  in  middle  life.  When 
they  are  situated  on  the  face,  it  is  generally  desirable  to  let  them 
alone,  for  if  they  are  small  they  often  adorn  it,  while  if  large 
there  is  risk  of  leaving  scars.  They  may  be  removed  by  caustics, 
such  as  potassa  fusa  (Bryant  and  Anderson). 

MOTHER'S  MARK.     (See  Nsevus). 

MILIUM. 

A  milium  is  a  little  round  slightly  elevated,  pearly-white 
spot,  about  the  size  of  a  millet-seed  or  larger.  They  are  scat- 
tered over  the  surface  in  variable  numbers,  but  are  principally 
met  with  on  the  face,  especially  near  the  eyes,  and  on  the  eye- 
lids (Anderson) 

Cause. — Obliteration  of  the  glandular  duct  and  retention  of 
the  sebaceous  matter  is  the  sole  cause. 

Treatment. — Consists  in  puncturing  the  upper  wall  of  each 
milium  and  expressing  its  contents  (Anderson). 


858  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

MUSCULAR  RHEUMATISM.     (See  Myalgia). 
MORBUS  COXARIUS. 

Is  a  disease  of  the  hip -joint. 

Causes. — The  disease  may  begin  as  a  synovitis,  or  it  may  be- 
gin in  a  rupture,  partial  or  complete  of  the  ligamentum  teres, 
thereby  interfering  with  the  nutrition  of  the  head  of  the  femur. 
It  may  begin  from  rupture  of  some  minute  blood  vessels  in  the 
bone  just  beneath  the  cartilage.  The  synovitis  is  almost  always 
the  result  of  exposure  to  sudden  changes  of  temperature  after 
violent  exercise,  such  as  skating,  racing,  jumping,  playing  at 
foot-ball  and  other  movements  that  over  exercise  the  joint.  In 
other  words  morbus  coxarius  is  almost  invariably  due  to  a  trau- 
matic cause,  and  not  dependent  upon  some  constitutional  taint, 
as  scrofula,  etc.  (Sayre). 

Symptoms. — There  are  three  stages:  1.  The  stage  of  irrita- 
tion or  of  limited  motion,  before  the  occurrence  of  effusion.  2.  The 
stage  of  apparent  lengthening,  or  of  effusion,  the  capsule  of  the 
joint  remaining  entire.  3.  The  stage  of  shortening,  or  of  ruptured 
capsule.  The  first  thing  that  attracts  the  attention  of  the  patient 
is  generally  a  stiffness  about  the  joint  and  a  limping  gait  in  the 
morning.  In  the  first  stage,  there  will  be  slight  abduction  and 
slight  flexion  at  the  knee  and  hip.  Abduction,  adduction,  and 
rotation  are  also  limited.  There  is  atrophy  of  the  thigh  or  entire 
limb.  There  are  pain  and  tenderness.  The  pain  may  be  re- 
ferred to  the  knee,  and  thus  mislead  the  surgeon.  In  the  second 
stage,  the  pain,  tenderness,  swelling,  atrophy,  and  limited  motion 
of  the  first  stage  are  increased  in  severity.  The  limb  is  appar- 
ently longer,  abducted,  everted,  and  flexed  in  both  joints.  The 
foot  touches  the  ground  with  the  sole.  The  toes  are  everted  as 
in  fracture  of  the  neck.  The  pelvis  is  lowered  on  the  diseased 
side,  and  projects  forward.  The  natis  is  low  and  flat.  The  pain 
is  most  intense.  In  the  third  stage,  the  capsule  ruptures  and  the 
fluid  escapes  into  the  surrounding  tissues  and  the  patient  is  com- 
paratively free  from  pain.  The  limb  is  shorter,  adducted,  in- 
verted, and  flexed  in  the  hip-joint  only.  The  foot  touches  the 
ground  with  the  ball  only.     The  toes  are  inverted.     The  pelvis 


njevus.  359 

is    raised,   projected   backward,  and  natis    is   high    and   round 
(Sayre). 

Treatment. — Is  both  local  and  general.  The  general  treat- 
ment will  consist  of  tonics,  cod  liver  oil,  stimulants,  good  food 
and  hygienic  surroundings,  sunlight  and  frequent  baths.  The 
local  treatment  consists  of  absolute  rest  and  freedom  from  pres- 
sure of  the  parts  involved  in  the  disease  (extension).  If  milder 
measures  fail,  exsection  of  the  joint  is  justifiable  (Sayre). 

N^EVUS. 

Is  essentially  a  disease  of  the  capillaries  and  is  made  up  of 
a  mass  of  vascular  tissue.  Naevi  are  almost  always  congenital. 
Some  naevi  are  pigmentary  and  are  then  termed  "  moles  "  (Bry- 
ant). 

Situation. — Their  commonest  situation  is  in  the  skin  and 
subcutaneous  tissue,  and  occurs  on  the  head  and  face  much  more 
frequently  than  elsewhere.  If  entirely  subcutaneous  the  skin  is 
not  discolored,  but  if  the  naevus  invade  the  skin  there  is  a  dis- 
coloration of  its  surface,  or  a  pedunculated  outgrowth  like  a 
piece  of  cock's  comb  (Anderson). 

Varieties. — There  are  three  varieties  of  naevus — arterial,  ven- 
ous, and  capillary  according  as  arterioles,  veins,  or  capillaries 
predominate  in  their  structure.  Arterial  and  venous  naevi  are 
always  congenital  and  subcutaneous.  They  may  be  emptied  by 
pressure.  The  morbid  erectile  tissue  of  the  venous  naevi  resem- 
ble pretty  closely  natural  erectile  tissue  of  the  penis  and  nipple. 
A  capillary  naevus  called  also  "  mother's  mark,"  "  port  wine 
mark "  or  "  strawberry  mark,"  is  the  most  disfiguring,  but  the 
least  harmful  of  the  three  varieties.  It  occurs  more  frequently 
on  the  head,  face,  neck,  shoulders  and  arms  than  elsewhere;  and 
consists  of  bright  red  or  purple  patches  on  the  surface  of  the 
skin.  It  is  sometimes  prone  to  take  on  unhealthy  ulceration.  At 
birth  these  naevi  are  often  no  larger  than  a  pin  point,  but  may 
grow  rapidly  (Anderson). 

Treatment. — The  methods  of  treatment  are  various.  The 
artery  leading  to  the  naevus  may  be  ligated.  The  part  in  which 
the  naevus  is   situated  may  be   amputated.     The  naevus  may  be 


360  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

injected  with  various  astringent  fluids.  The  actual  cautery, 
various  caustics  and  electrolysis  have  been  tried.  Multiple 
punctures  and  scarifications  of  port  wine  stains  have  been  em- 
ployed, but  it  is  not  very  successful  (Anderson).  For  small 
superficial  birthmarks,  S.  D.  Gross  applies  with  a  brush  locally 
sixteen  grains  of  corrosive  sublimate  to  half  an  ounce  of  collo- 
dion.    Bartholow  recommends  the  following  : 

R     Acicli  chromici giss. 

Aquse  destillatse §j . — M. 

Sig. :     Apply  with  care  locally. 

Waring  paints  the  spot  daily  with  creosote. 

NECROSIS. 

Is  the  death  or  mortification  of  bone,  and  is  applied  to  cases 
in  which  part  of  the  shaft  of  the  bone  dies. 

Causes. — Injury  or  violent  inflammation.  •  Necrosis  of  the 
lower  jaw  frequently  results  from  the  inhalation  of  the  fumes  of 
phosphorus  by  persons  employed  in  lucifer  match  factories. 
The  bone  in  necrosis  dies  from  obstruction  of  its  circulation 
(Bryant). 

Treatment. — The  indication  is  to  remove  the  sequestrum  as 
soon  as  it  is  sufficiently  loose.  It  may  require  an  incision  if  the 
dead  bone  is  large  (Bryant). 

NEPHRITIS.     (See  Bright's  Disease.) 

NETTLE  RASH.     (See  Urticaria.) 

NEURALGIA, 

Is  a  functional  affection  of  which  the  chief  characteristic  is 
pain.  In  a  purely  neuralgic  disease  there  is  neither  inflamma- 
tion nor  any  appreciable  lesion  in  the  painful  part  (Flint). 

Causes. — Neuralgia  is  often  an  hereditary  disease.  Any  dis- 
ease causing  anaemia  is  a  marked  predisposing  cause.  Among 
exciting  causes  are  damp,  cold,  lead,  mercury,  traumatism  and 
chronic  blood  poisoning.  Reflex  neuralgia  is  induced  by  genito 
urinary  diseases,  decayed  teeth,  dyspepsia,  worms,  constipation, 


NEUKALGIA. 


361 


etc.  Neuralgia  may  follow  or  accompany  herpes  zoster.  It  is 
rare  before  puberty,  and  most  frequent  between  20  and  50  years 
of  age.     Women  are  more  liable  than  men  (Loomis). 

Symptoms. — The  pain  is  at  first  intermitting,  later  it  is  con- 
tinuous with  slight  remissions.  It  may  be  dull,  boring,  stabbing, 
tearing,  or  darting,  and  is  confined  to  the  course  of  a  nerve. 
Turning  and  coughing  increase  the  pain.  Increase  of  pain  on 
pressure  is  an  important  point.  Tri-facial  neuralgia  is  one  of  the 
most  common  forms.  It  is  usually  attended  with  painful  spasm, 
called  tic  douloureux.  Clavis  hystericus  is  a  variety  of  tic  in 
which  there  is  a  sensation  as  of  a  nail  being  driven  into  the 
skull.     It  is  usually  met  with  in  anaemic  females. 

Sciatica  is  a  neuralgic  affection  of  the  sensory  nerves  of  the 
sciatic  plexus.  It  may  be  caused  by  pressure  of  tumors,  by 
caries  of  vertebrae  and  by  rheumatism  as  the  result  of  taking  cold. 
Chronic  malarial  infection  may  be  the  cause  of  sciatica.  The  pain 
is  more  intense  at  night.  Cramps  in  the  muscles  of  the  legs  are 
common.  It  is  a  very  obstinate  affection  lasting  from  six  weeks 
to  two  months,  though  it  may  last  for  years.  Relapses  are  com- 
mon (Loomis). 

Intercostal  neuralgia  is  an  affection  of  any  of  the  dorsal 
nerves;  the  anterior  branches  of  two  or  three  of  the  nerves  upon 
the  left  side  are  those  usually  affected.  It  occurs  in  women  as  a 
rule.  The  pain  is  intermittent,  tearing  or  stabbing  in  character, 
increased  by  coughing  or  sneezing. 

There  are  three  diagnostic  points  of  tenderness;  namely,  at 
the  exit  of  the  nerves  from  the  spine,  at  the  side  of  the  chest 
where  they  become  subcutaneous,  and  near  the  sternum  or 
median  line  at  the  terminal  branches.  Cardiac  palpitation, 
dyspnoea,  nausea  and  vomiting  are  frequent  symptoms  of  inter- 
costal neuralgia.  Herpes  zoster,  intolerable  itching,  and  attacks 
of  angina  pectoris  often  complicate  it. 

Cervico- occipital  neuralgia  is  usually  attended  with  pain 
along  the  course  of  the  occipitalis  major,  and  often  resembles  that 
form  of  muscular  rheumatism  called  torticollis,  or  wry  neck. 

Coccyodynia  is  common  in  women,  and  is  due  to  neuralgia 
of  the  coccygeal  plexus  (Loomis). 


/ 
362  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — Neuralgia  has  been  well  said  to  be  the  cry  of  a 
nerve  for  better  blood.  If  there  be  anaemia,  a  good  diet,  cod-liver 
oil,  the  hypophosphites,  quinine,  iron  and  strychnia  should  be 
ordered.  Neuralgia  due  to  syphilis  demands  iodide  of  potassium; 
to  rheumatism,  the  anti- rheumatics;  to  gout,  colchicum;  and  to 
malaria,  quinine,  but  in  many  non- malarial  cases  also,  especially 
in  tic,  quinine  is  the  most  effectual  remedy. 

Local  Treatment. — Blisters,  galvanic  current,  chloroform, 
opium,  belladonna,  veratria  liniments,  and  cold  or  very  hot  water 
may  be  applied,  and  usually  these  remedies  afford  relief.  Acon- 
ite is  an  effective  remedy  applied  locally.  Firing,  sinapisms  and 
the  actual  cautery  are  frequently  beneficial.  A  warm  dry  climate 
is  favorable.  Morphine  is  the  most  effective  for  immediate  relief 
of  pain.  Neuralgic  attacks  and  headache  that  are  accompanied 
by  flushing  of  the  face  are  often  relieved  by  ergot.  But  when 
the  face  is  very  pale,  nitrite  of  amyl  is  to  be  preferred.  Good 
results  are  obtained  by  the  use  of  antipyrin.  In  severe  chronic 
neuralgias  a  portion  of  a  nerve  may  be  excised.  In  sciatica 
nerve  stretching  is  effective  in  some  cases  (Loomis). 

PRESCRIPTIONS  FOR  NEURALGIA. 

R     Menthol gr.  xxiiss. 

Cocaini  muriatis gr.  viiss. 

Chloral  hydratis gr.  ivss. 

Vaselini giiss. — M. 

Ft.  ungt. 
Sig.:     Apply  to  the  painful  part  and  cover  with  a  strip  of  court 
plaster.  — Galezowski. 

R     Menthol 3J- 

Linementi  saponis  comp gij. — M. 

Sig.:     Use  locally.  — Witherstine. 

R     Quinise  sulphatis gj. 

Morphias  sulphatis gr.  iss. 

Strychnia  sulphatis gr.  j. 

Extracti  aconiti gr.  xv. 

Acidi  arseniosi gr.  iss. — M. 

Ft.  massa  et  in  pil.  no.  xxx.  div. 
Sig.:     One  pill  thrice  daily.  — S.  D.  Gross. 


NIPPLES NYMPHOMANIA.  363 

li     Chloral  hydrastis 

Pulv.  camphorse aa ^iv. — M. 

Sig. :     Apply  with  a  camel's  hair  brush.  — Geo.  Bird. 

NIPPLES.     (Sore). 

Sore  nipples  are  sources  of  great  distress  and  too  often  the 
precursors  of  mammary  abscess. 

Causes. — They  are  doubtless  often  caused  by  some  aphthous 
condition  of  the  child's  mouth,  but  they  frequently  result  from 
some  unusual  sensibility  of  the  skin  of  the  part,  and  at  times 
from  want  of  care.  A  simple  erythema,  associated  with  great 
tenderness,  is  a  common  trouble  at  the  beginning  of  lactation  to 
which  primiparse  are  more  subject  than  multipara  (Lusk). 

Treatment. — It  is  a  good  plan  to  anticipate  this  difficulty  by 
instructing  the  patient  to  wash  the  nipples  daily  during  the  last 
weeks  of  pregnancy  with  some  astringent  or  alcoholic  solution. 
In  child-bed,  in  addition  to  strict  cleanliness,  great  benefit  is  de- 
rived from  folding  a  linen  rag  around  the  nipple  and  keeping  it 
constantly  wetted  with  Goulard's  extract,  a  teaspoonful  to  a 
tumbler  of  water,  until  the  sensitiveness  and  redness  have  dis- 
appeared. Before  applying  the  child  to  the  breast,  care  should 
be  taken  to  wash  away  the  deposited  carbonate  of  lead.  Where 
the  nipples  are  not  sufficiently  prominent,  a  breast  glass  or 
gutta-percha  shield  should  be  worn.  The  applications  of  glycer- 
ine of  tannic  acid,  Richardson's  styptic  colloid,  tincture  of  cat- 
echu, a  solution  of  nitrate  of  silver  gr.  v.  to  the  ounce  of  water, 
and  an  ointment  of  extract  of  rhatany  gr.  viii.  mixed  with  5.  ii. 
of  the  oil  of  theobroma,  are  good  applications.  Castor  oil  as  sen 
external  application  or  collodion  is  sometimes  useful  (Lusk  and 
Bryant).     (See  also  fissures  of  the  nipples). 

NYMPHOMANIA. 

Is  an  irresistible  sexual  desire  in  females.  It  is  the  analogue 
of  satyriasis. 

Causes. — As  a  rule,  nymphomania  is  caused  by  cerebral 
lesions.     It  is  also  a  functional  nervous  affection  (Bartholow  ). 

Treatment. — Twenty  grains  of  the  bromide  of  potassium 
thrice  daily  will  exert  a  decided  control   over  excessive  sexual 


364  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

propensity  (Ringer).  As  a  rule,  nymphomania  dependent  on 
cerebral  lesions  are  not  diminished  or  prevented  by  the  bromides 
(Bartholow).  Large  doses  of  camphor  (from  five  to  twenty 
grains)  diminish  the  venereal  appetite  and  the  vigor  of  the  erec- 
tions, and  are  therefore  useful  in  priapism,  satyriasis,  nympho- 
mania, chordee,  etc.  (Bartholow).  There  is  no  doubt  that  ex- 
cessive use  of  tobacco  lessens  the  venereal  appetite;  hence, 
slightly  nauseating  doses  of  the  wine  of  tobacco  will  effectively 
check  chordee,  priapism,  satyriasis  and  nymphomania  (Bartho- 
low). 

NAUSEA.     (See  Vomiting.) 

NEURITIS. 

Is  an  inflammation  of  a  nerve  or  nerves.  Varieties:  1.  Sim- 
ple neuritis.  2.  Toxic  neuritis.  3.  Diathetic  neuritis.  4.  Mul- 
tiple neuritis. 

Causes. — Simple  neuritis  is  produced  by  wounds,  injuries, 
and  extension  of  inflammation  from  adjacent  tissues,  as  an  inter- 
costal neuritis  is  caused  by  an  adjacent  pleuritis  or  tuberculosis 
of  the  lung;  sciatica,  by  a  pelvic  abscess  or  inflamed  haemor- 
rhoids. Toxic  neuritis  is  caused  by  lead,  copper,  arsenic,  etc. 
Diathetic  neuritis  arises  from  some  systemic  condition,  such  as 
rheumatism,  gout,'  syphilis,  etc.,  and  septic  diseases.  The  cause 
of  multiple  neuritis  is  not  known  (Bartholow).  Alcohol  must' 
be  recognized  as  an  unquestioned  cause,  especially  of  chronic 
neuritis.  Exposure  to  cold  and  sexual  excess  are  frequent  causes 
(Loomis). 

Symptoms. — There  may  be  chilliness  followed  by  fever, 
headache,  and  general  muscular  soreness.  The  most  prominent 
symptom  is  pain  in  the  nerve.  The  pain  is  of  a  very  distressing 
kind;  it  is  a  burning,  tingling,  tearing  and  intense  pain,  and  is 
increased  by  motion  or  pressure.  At  first,  there  is  great  sensi- 
-tiveness  in  the  inflamed  nerve,  and  ultimately  the  parts  supplied 
by  the  nerve  become  amesthetic,  then  will  follow  paresis,  and 
finally  paralysis,  if  the  nerve  is  compressed  or  destroyed.  Wast- 
ing and  degeneration  of  the  muscles  are  results  of  neuritis. 
Various  forms  of  cutaneous  eruptions  appear,  as  herpes,  eczema 


NEURITIS NIGHTMARE NIGHT -SCREAMING.  365 

and  glossy  skin;  the  nails  become  clubbed,  the  hair  falls  out,  and 
the  joints  swell  and  change  in  structure.  The  reflexes  are 
diminished  (Bartholow). 

Differential  Diagnosis. — Neuritis  may  be  mistaken  for  neural- 
gia. In  neuralgia  the  pain  is  paroxysmal;  there  are  isolated 
points  of  tenderness  and  absence  of  paralysis.  In  neuritis  the 
reverse  (Flint). 

Prognosis. — Is  very  uncertain. 

Treatment. — In  acute  cases,  leeches  may  be  applied  along  the 
course  of  the  nerve,  if  the  patient  be  vigorous.  A  fall  dose  of 
morphine  and  quinine  should  be  given  at  once  (gr.  ss.-gr.  xv.  for 
an  adult),  and  two  drops  every  two  hours  of  the  tincture  of 
aconite  root.  In  chronic  cases  the  most  effective  remedies  are 
galvanism  and  morphine.  The  electric  brush,  blisters  and  the 
oleate  of  morphine  may  be  used  locally,  and  iodide  of  potassium 
internally  (Bartholow). 

NIGHTMARE. 

Is  a  sensation  in  sleep,  as  of  a  pressure  of  a  weight  on  the 
chest  or  stomach,  and  of  an  impossibility  of  speech,  motion,  or 
respiration,  from  which  one  wakes  after  extreme  anxiety,  in  a 
troubled  state  of  mind  (Dunglison). 

Treatment. — The  bromide  of  potassium  is  the  most  effective 
remedy  for  nightmare  (Ringer). 

NIGHT=SCREAMING. 

Is  a  symptom  which  appears  to  be  allied  to  nightmare 
(Ringer). 

Treatment, — Bromide  of  potassium  is  of  great  service  in  the 
treatment  of  children  subject  to  night- screaming.  Children 
from  a  few  months  to  several  years  old  may  be  attacked  with  this 
affection.  Sometimes  the  attack  occurs  only  once  or  twice  a 
week,  or  it  may  be  repeated  several  times  each  night.  The 
screaming  may  last  only  for  a  few  seconds  or  it  may  endure  for 
several  hours.  The  child  is  generally  horribly  frightened.  With 
the  screaming  and  fright,  squinting  sometimes  occurs,  which 
after  some  time  becomes  permanent.     In  these  cases  bromide  of 


366  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

potassium  will  prevent  the  screaming  and  remove  the   squinting. 
This  screaming  in  children  is  very  generally  connected  with 
deranged  digestion,  which  should  be  treated  (Ringer). 

NEURASTHENIA.     (See  Asthenia). 
OBESITY. 

Is  the  excessive  accumulation  of  fat  in  the  organism. 

Causes. — The  accumulation  of  fat  in  the  organism  is  the  re- 
sult of  its  incomplete  oxidation.  It  may  be  due  to  excessive  sup- 
ply or  excessive  formation  of  fat.  Too  abundant  ingestion  of 
rich  food,  especially  of  fat  and  carbohydrates,  leads  to  obesity. 
The  tendency  to  obesity  may  be  hereditary  or  acquired.  In  the 
former  it  is  cured  with  difficulty;  in  the  latter  a  suitable  regimen 
will  accomplish  much.  The  use  of  alcohol  favors  the  accumula- 
tion of  fat  by  diminishing  its  normal  oxidation  (Bartholow  and 
Flint). 

Treatment. — In  the  treatment  of  obesity,  it  is  necessary  to 
withdraw  all  fats,  starches  and  sugars  from  the  diet.  This  is  the 
method  of  Mr.  Banting,  now  called  Bantingism.  Obesity,  which 
is  frequently  diminished  by  a  course  of  alkalies,  is  better  treated 
by  alkaline  waters,  for  at  the  springs  these  patients  can  be  in- 
duced, more  easily  to  conform  to  the  plan  of  exercise  and  diet 
necessary  in  these  cases.  It  is  stated  that  the  bromides,  especi- 
ally bromide  of  ammonium,  diminish  the  deposition  and  hasten 
the  retrograde  metamorphosis  of  the  fat  in  obesity.  Permanga- 
nate of  potassium  has  also  appeared  to  be  very  serviceable  as  a 
remedy  for  an  abnormal  and  excessive  deposition  of  fat.  The 
vegetable  acids  are  sometimes  taken  by  young  ladies  to  keep 
down  the  formation  of  fat;  but  it  accomplishes  this  object  by  im- 
pairing digestion  (Bartholow). 

Dr.  Neligan  states  that  he  has  often  removed  an  uncomfort- 
able excess  of  fat  by  the  use  of  liquor  potassse,  without  in  any 
-way  injuring  the  patient's  general  health. 


OBESITY ONYCHIA    MALIGNA.  367 

PRESCRIPTIONS  FOR  OBESITY. 

]£     Potassii  permanganate gr.  vj.-xxiv. 

Aquae  destillatse giij— M. 

Sig. :     A  teaspoonful  three  times  a  day.  — Bartholow. 

{&     Liquoris  potassee Sij. 

Sig. :     A  half  teaspoonful  in  milk  thrice  daily.  —Waring. 

(EDEMA.     (See  Dropsy.) 

ONYCHIA  MALIGNA. 

This  is  a  disease  of  the  nail  matrix. 

Causes. — It  is  most  commonly  found  in  unhealthy  children, 
and  as  a  rule  is  started  by  some  local  injury  such  as  a'  squeeze 

(Bryant). 

Symptoms. — It  commences  as  a  swelling  of  the  end  of  the  toe 
or  finger,  with  redness,  heat  and  pain.  These  symptoms  are 
soon  followed  by  exudation  from  beneath  the  nail  of  a  serous 
and  often  fetid  fluid;  the  nail  itself  loosens,  sometimes  falls  off, 
or  either  flattens  out  or  curls  up  at  its  edges.  In  rare  instances 
the  disease  involves  the  last  phalangeal  joint  or  bone.  The 
fingers  and  thumbs  of  both  hands  may  be  involved,  and  the 
disease  may  exist  for  years  (Bryant). 

Treatment. — In  mild  cases,  tonics  internally  and  water  dres- 
sing externally,  suffice  to  bring  about  a  cure.  In  severe  cases,  it 
may  be  necessary  to  take  away  nail  and  soft  parts  and  even  the 
extreme  phalanx.  The  application  of  the  powdered  nitrate  of 
lead  to  the  ulcer  has  been  strongly  recommended.  The  disease 
at  times  may  have  a  syphilitic  origin  when  it  will  be  wise  to 
adopt  specific  treatment  (Bryant).  Ringer  recommends  mercury 
ointment  applied  for  ten  minutes  every  hour,  and  poultices  at 
other  times.  He  also  advises  nitrate  of  lead  to  be  dusted  on  the 
diseased  tissues  night  and  morning.  Bartholow  applies  a  solu- 
tion of  chloral  to  the  part  or  iodoform  in  powder  or  ointment. 


368  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

OPHTHALMIA. 

Is  an  inflammation  of  the  eye.  It  is  a  severe  form  of  con- 
junctivitis called  purulent. 

Varieties. — Ophthalmia  neonatorum  which  occurs  in  infants 
at  or  soon  after  birth,  and  gonorrhceal  oimthalmia  which  occurs 
in  adults  (Noyes). 

Causes. — In  both  classes  the  disease  is  essentially  the  same, 
and  originates  from  a  contagion  in  the  great  majority  of  cases. 
This  contagion  is  the  gonococcus. 

Ophthalmia  Neonatorum. — At  birth  the  eye-lids  are  al- 
ways agglutinated  by  the  parturient  secretions.  It  is  common 
too  for  the  eye-lids  to  remain  red  and  sticky  for  a  day  or  two. 
The  great  proportion  of  these  simple  cases  will  not  require  ser- 
ious attention,  and  will  clear  up  if  the  eyes  be  washed  with  warni 
milk  and  water,  or  with  a  solution  of  boracic  acid  several  times 
a  day.  But  it  is  the  purulent  form  due  to  gonorrhoea  which  de- 
mands active  treatment.  In  this  form  there  is  swelling  of  the 
lids  with  thick  yellow  secretion  issuing  from  the  eyes.  The 
cornea  may  ulcerate  (Noyes). 

Prophylaxis, — The  importance  of  preventing  this  disease  will 
be  appreciated  when  it  is  learned  that  nearly  one  third  of  the 
inmates  of  blind  asylums  were  made  blind  by  this  disease. 
"Where  there  is  a  suspicion  of  gonorrhoea,  the  vagina  may  be 
washed  out  for  some  time  before  parturition  and  while  labor  is 
going  on  with  a  three  per  cent  solution  of  carbolic  acid.  As  soon  as 
the  child  is  born,  Crecle  drops  a  single  drop  of  a  two  percent,  so- 
lution (gr.  x.  to  §j.)  of  nitrate  of  silver  between  the  lids  of  each 
eye.     Dr.  ISToyes  thinks  a  one  per  cent  solution  will  suffice. 

Treatment. — At  first  when  the  secretion  is  watery,  cold  lotions 
and  three  per  cent,  solution  of  boracic  acid  may  be  used.  As  soon 
as  the  secretion  grows  a  little  thicker,  and  the  swelling  of  the 
lids  grows  less,  a  solution  of  nitrate  of  silver  (gr.  v— gr.  x  to  5j.) 
may  be  applied  to  the  everted  lids,  carefully  avoiding  the  cornea, 
once  in  24  hours  (Noyes).  Gonorrhoea!  ojDhthalinia  in  adults  is 
essentially  the  same  disease  as  ophthalmia  neonatorum.  The 
gonorrhceal  poison  is  conveyed  to  the   eyes  through  the  fingers, 


OPIUM    HABIT.  369 

handkerchiefs,  towels,  etc.,  from  acute  or  chronic  gonorrhea 
(Noyes). 

Symptoms. — Are  hyperemia,  swelling  of  the  lids  which 
speedily  closes  them,  and  at  first  a  thin  discharge.  The  secretion 
in  a  little  time  becomes  more  and  more  purulent.  Ulceration 
of  the  cornea  may  occur. 

Treatment. — The  jDatient  should  go  to  bed.  Four  to  six 
leeches  may  be  put  upon  the  temple  in  robust  subjects.  Con- 
tinuous cold  applications  must  be  kept  to  the  eye.  Absolute 
cleanliness  is  imperative.  Boracic  acid  four  per  cent,  solution 
must  be  used  to  cleanse  the  eyes.  When  the  secretion  becomes 
creamy  and  distinctly  purulent,  a  solution  of  nitrate  of  silver 
(gr.  x.  to  oj.)  may  be  applied  to  the  everted  lids,  care  being- 
taken  to  avoid  the  cornea.  This  is  applied  once  in  twenty-four 
hours.  Should  the  cornea  become  invaded,  a  solution  of  atro- 
pine sulphate  (gr.  ij.  to  oj.)  should  be  instilled  every  three  to 
six  hours  (Noyes).  Crecle  irrigates  the  eye  frequently  with  a 
solution  of  corrosive  sublimate  (gr.  j.  to  oxij.). 

OPIUM  HABIT. 

In  chronic  opium  poisoning,  the  opium  is  not  always  taken 
by  the  mouth;  it  may  be  taken  in  the  form  of  morphine  hypo- 
dermically.  Some  persons  take  thirty  grains  of  morphine  per 
day.  Opium  eaters  are  entirely  unreliable.  They  are  chronic 
liars,  owing  to  their  incapacity  to  tell  the  truth. 

Not  all  persons  will  contract  this  habit,  but  in  a  minority  of 
people  opium  is  unu&ually  pleasant,  and  these  are  the  persons 
who  are  most  liable  to  become  opium  eaters.  Opium  affects  some 
people  unpleasantly.  Many  smoke  opium  and  say  they  can  get 
effects  which  they  cannot  get  in  any  other  way.  The  opium 
habit  is,  as  a  rule,  contracted  unconsciously.  In  order  to  get  the 
effect  which  we  get  at  first,  it  is  necessary  to  increase  the  dose. 
Neuralgic  patients  often  become  opium  eaters.  In  some  it  stim- 
ulates the  mental  faculties.  De  Quincey  took  320  grains  daily 
and  wrote  beautifully.  Opium  is  a  much  more  dangerous  drug 
than  alcohol.  The  opium  habit  is  much  harder  to  break  up  than 
the  alcohol.     Any  one  who   takes   two   grains   of  morphine  or 


370  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

more  in  twenty- four  hours  inight  be  said  to  have  contracted  the 
opium  habit.  In  chronic  opium  poisoning  the  pupils  are  usually 
contracted.  Later  on  it  takes  a  large  amount  to  cause  this  con- 
traction of  the  pupil.  A  chronic  opium  eater  is  apt  to  complain 
of  pain  which  varies  in  location  from  time  to  time. 

This  is  done  with  a  view  to  justify  the  taking  of  opium. 
Such  patients  are  great  seekers  of  sympathy;  are  subject  to 
vomiting.  At  first  opium  is  apt  to  cause  constipation,  but  later 
on,  if  continued,  it  usually  causes  diarrhoea.  An  obstinate  form 
of  diarrhoea  should  always  create  suspicion  (A.  A.  Smith). 

Diagnosis. — Always  examine  the  urine  or  perspiration  for 
opium.  A  very  small  quantity  in  these  fluids  may  be  detected. 
This  should  be  done  when  the  patient  will  not  own  up  (Smith). 

Results. — The  chronic  opium  habit  will  destroy  a  man  men- 
tally, physically  and  morally.  Eenal  disease  is  very  apt  to 
develop  sooner  or  later  because  of  changes  in  the  nervous  system. 
Myocarditis  of  a  sub -acute  character  is  apt  to  develop.  Pneu- 
monia in  such  cases  is  apt  to  be  fatal.  Opium  causes  a  man  to 
become  old  while  yet  young.  It  hastens  degenerative  changes. 
There  is  oedema  in  the  lower  extremities  usually  in  chronic 
opium  eaters.     It  destroys  the  will  power  (A.  A.  Smith). 

Treatment. — Two  methods  of  curing  the  habit  may  be 
adopted  :  1.  Cut  it  off  short.  Prof.  Flint  advocated  this 
method  most  of  his  life,  but  altered  his  opinion  later.  2.  Grad- 
ually withdraw  the  drug.  This  is  the  best  method.  When  we 
think  we  are  getting  the  patient  down  to  two  grains  a  day  (from 
thirty  grains  per  day),  he  is  probably  taking  a  great  deal  more. 
If  such  a  patient  who  is  thought  to  be  taking  a  small  amount  of 
opium  feels  well  and  does  not  complain  of  any  inconvenience,  we 
may  know  that  he  is  deceiving  us.  He  will  even  bribe  his  nurse. 
It  requires  the  most  careful  watching  in  such  cases,  else  he  will 
deceive  us.  The  more  rigid  and  positive  we  may  be  the  better 
for  the  patient.  If  the  patient  has  been  taking  30  grains  per 
day,  Prof.  Smith  always  tries  to  get,  him  down  to  one  grain  per 
day  in  30  days.  Should  keep  the  patient  under  treatment  for  at 
least  six  months.  Build  up  and  improve  the  digestion  as  the 
dose  of  opium  is  reduced.  The  horrors  which  opium-eaters 
suffer  when  the    drug  is   withheld    are  well  known;  so   great, 


OPIUM    HABIT ORCHITIS.  371 

indeed,  is  the  suffering  that  few  have  sufficient  resolution  to  re- 
linquish it.  Ringer  thinks  that  moderate  indulgence  of  the 
habit  is  not  perhaps  more  prejudicial  to  health  than  tobacco  - 
smoking. 

PRESCRIPTIONS  FOR  OPIUM  HABIT. 

R     Ext.  cannabis  indicae Sij. — (Squibb). 

Sig. :     A  teaspoonful  every  hour  or  two,  as   required.     (For  rest- 
lessness). — Mattison. 

R     Zinci  oxidi gss. 

Syrupi  simplicis q.  s. 

Ft.  massa  et  in  pil  no.  xxx.  div. 
Sig. :     One  pill  once  daily  increasing   to   tolerance.     (For  vomit- 
ing and  diarrhoea).  — DaCosta. 

R     Spartein  sulphatis gr.  j. 

Aquae  destillatse gj . — M. 

Sig. :     Ten  minims  hypodermically,  for  the  collapse  produced  by 
withdrawing  the  drug.  — Ball. 

R     Tincturse  nucis  vomica? gtt.  xij. 

Acidi  phosphorici  dil gtt.  xx. 

Syr.  pruni  Virg gss. — M. 

Sig. :     To  be  taken  twice  daily. 

ORCHITIS. 

Is  an  inflammation  of  the  testicles. 

Causes. — True  orchitis  is  very  uncommon.  As  complicating 
mumps,  no  rational  theory  has  been  advanced  to  account  for  it. 
Orchitis  due  to  mumps  is  most  often  observed  at  about  the  age 
of  puberty.  It  occurs  in  about  five  per  cent,  of  the  cases.  It 
comes  on  near  the  end  of  the  first  week  of  the  mumps  and  is  us- 
ually confined  to  a  single  testicle.  The  affection  runs  a  quick 
course  of  about  a  week  or  ten  days,  and  usually  clears  up. 
Orchitis  after  severe  injury  to  the  testis  is  not  uncommon.  It 
tends  to  terminate  in  abscess  or  gangrene.  Orchitis  as  a  result 
of  cold  is  possible.  Excessive  sexual  excitement  has  been  ad- 
duced as  a  cause.  It  may  complicate  variola,  typhoid  fever  and 
gout.  Orchitis  may  come  on  secondarily  during  epididymitis 
(Keyes). 


372  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — In  true  orchitis  the  increase  in  the  size  of  the 
testis  generally  advances  rather  slowly.  The  pain  is  often  ex- 
cruciating, and  always  out  of  proportion  to  the  amount  of 
swelling.  It  has  been  compared  to  renal  or  hepatic  colic.  No 
position  gives  rest  and  any  handling  of  the  organ  is  liable  to  in- 
duce syncojDe.  If  the  pain  suddenly  ceases,  it  may  mean  mortifi- 
cation of  the  organ.  The  shape  of  the  testicle  is  rarely  altered 
in  orchitis.     The  organ  feels  indurated. 

Terminations. — It  may  terminate  in  gangrene,  in  complete 
resolution,  or  in  atrophy.  The  general  symptoms  are  often 
severe;  chills,  high  fever,  anorexia,  nausea,  vomiting,  hiccough, 
constipation,  sleeplessness,  anxiety  and  nervousness  (Keyes). 

Prognosis. — Is  always  grave. 

Treatment. — The  patient  should  be  put  to  bed,  with  the 
testicle  supported  in  a  sling.  If  the  case  is  seen  early,  ten  to 
fifteen  leeches  may  be  applied  in  the  neighborhood  of  the 
abdominal  ring.  The  testicle  may  be  enveloped  in  strong  bella- 
donna ointment,  or  a  paste  composed  of  powdered  opium  and 
glycerine,  or  if  the  pain  be  not  too  excruciating,  in  a  light  tobacco 
poultice.  Saline  cathartics  should  be  given.  The  diet  should 
be  low,  non- stimulating,  and  easily  digested.  On  the  slightest 
suspicion  of  gangrene,  it  is  wise  to  resort  to  subcutaneous  section 
of  the  tunica  albuginea  to  take  off  tension.  If  abscess  form  it 
should  be  opened  (Keyes). 

PRESCRIPTIONS  FOR  ORCHITIS. 

R     Tincturse  Pulsatillas Sss. 

Sig. :     One  to  three  drops  every  hour  or  two  in  water.     — Brown. 

R     Antimonii  et  potassii  tart gr.  j. 

Aqua?    o viij . — M. 

Sig. :     One  or  two  teaspoonfuls  every  hour  or  two.  — Ringer. 

R     Morphias  sulphatis  gr.  xvj. 

Hydrargyri  oleatis  (10  per  cent.)..§ij. — M. 
Sig.:     Apply  twice  daily.     (To  remove  induration).  — Marshall. 

R     Tincturas  iodi gss. 

Sig. :     Apply  to  swollen  testicle  after  acute  symptoms  are  over. 

— Bartholow. 


otitis.  373 

R     Sodii  salicylatis sss. 

Syrupi  sirnplicis gij. 

Aqure  menthae  pip ad gvj. — M. 

Sig. :     A  tablespoonful  every  hour  till  the  pain  is   relieved,  then 
every  four  to  six  hours.  — Pigornet. 

OTITIS. 

Is  an  inflammation  of  the  ear.  If  the  inflammation  is  con- 
fined to  the  external  ear,  it  is  called  otitis  externa;  if  confined  to 
the  middle  ear,  it  is  called  otitis  media;  if  to  the  internal  ear, 
otitis  interna. 

Otitis  externa  is  an  inflammatory  affection  of  the  external 
auditory  meatus  involving  the  cutaneous  tissues  of  that  canal, 
the  periosteum  of  the  osseous  part  of  the  canal,  and  the  mem- 
brana  tympani  (Purves). 

Causes. — Irritation  or  injuries  to  the  ear,  the  prolonged  use 
of  injections,  the  pressure  of  foreign  bodies,  the  passage  of  cold 
currents  of  air  or  water,  the  non- drying  of  the  ear  after  washing, 
the  presence  of  fungi,  and  anything  which  will  cause  congestion 
or  irritation,  are  causes. 

Symptoms. — The  patient  complains  of  a  continual  itching 
sensation  with  a  feeling  of  heat  and  dryness  in  the  canal.  There 
is  a  feeling  of  fullness  in  the  ear.  The  discharge  is  at  first 
watery,  but  finally  becomes  purulent. 

Treatment.- — Discover  and  treat  the  cause.  Frequent  injec- 
tions of  warm  water  are  useful.  If  there  are  foreign  bodies 
present  remove  them.     Prevent  the  formation  of  pus. 

Otitis  media  is  an  inflammation  of  the  middle  ear.  The 
symptoms  are  acute  pain  and  fever.  It  is  nearly  always  followed 
by  perforation  of  the  membrane.  The  treatment  is  to  evacuate 
the  pus  as  soon  as  formed.  Leeches,  opiates,  purgatives  and 
warm  water  injections  into  the  meatus  are  usually  found  suc- 
cessful. When  the  discharge  occurs,  the  ear  should  be  syringed 
with  lukewarm  water  to  which  is  added  an  antiseptic  (Purves). 


374  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

OTALGIA. 

Is  a  neuralgia  of  the  ear. 

Causes. — When  a  patient  complains  of  pain  in  the  ear,  and 
no  in "fl animation  is  found  either  in  the  external  or  the  middle" 
ear,  the  teeth  should  be  suspected  as  being  at  the  root  of  the 
trouble.  In  the  majority  of  cases  of  otalgia,  sufficient  dental  disease 
is  found  to  justify  the  belief  that  this  is  the  primary  cause,  and  the 
otalgia  simply  a  reflex  condition.  The  cause  of  otalgia  rupv  be 
malarial,  rheumatic  or  syphilitic  (Buck). 

Treatment. — If  the  cause  of  otalgia  be  a  carious  tooth,  it 
should  be  extracted  or  properly  filled.  In  any  case  discover  the 
cause  and  treat  it. 

PRESCRIPTIONS  FOR  OTITIS  AND  OTALGIA. 

B     Morphia?  muriatis gr.  v. 

Atropine  sulphatis gr.  j. 

Olei  olivse 3j. 

Glycerine 3iss. — M. 

Sig. :     Five  drops  in  the  ear  every  hour  till  relieved  (Otalgia). 

R     Acidi  carbolici 3j . 

Glycerine 3ix. — M. 

Sig.:     A  few  drops  in  the  ear  three  times  daily.         =Hartmann. 

OXALURIA. 

When  oxalate  of  calcium  occurs  constantly  in  the  urine,  it 
produces  the  so-called  oxaluria  or  oxalic  acid  diathesis,  and  is 
apt  to  lead  to  the  formation  of  the  mulberry  calculi  and  in  time 
exert  its  poisonous  effects  on  the  brain  and  spinal  cord  (Loomis). 
Sometimes  the  crystals  appear  accidentally  in  the  urine  from  the 
free  use  of  rhubarb  or  tomatoes.  Disturbed  or  exhausted  nerve 
power  and  imperfect  digestion,  nervous  prostration  produced  by 
excessive  venery  and  over  stimulated  or  ungratified  sexual  desires 
are  associated  often  with  oxaluria  (Keyes). 

Treatment. — If  enough  of  any  alkali  be  given  to  render  the 
urine  abundant  and  limpid,  the  oxalate  of  lime  will  occasionally 
disappear  for  a  time.  Baths  are  beneficial.  The  true  curative 
treatment  is  purely  hygienic  and  based  upon  a  correct    apprecia- 


OXALURIA OZGEXA 


375 


tion  of  the  causes.  The  mineral  acids  and  stry chine  seem  some- 
times to  do  good  as  tonics;  an  outdoor  life  sometimes  cures 
(Keyes). 

PRESCRIPTIONS  FOR  OXALURIA. 

R     Acidi  nitro-muriatici  dil .3ij-jiij- 

Tinct.  gentians  comp 

Tinct.  cinchona?  comp. — aa Sj. 

Elixir  curacoa ad §iij .— M. 

Sig. :     A  dessertspoonful  in  a  wineglassful  of  water  thrice  daily. 

— Ringer. 

R     Glyceriti  pepsina? Siss. 

Acidi  lactici ad Sij— M. 

Sig.:     A  teaspoonful  after  meals.  — Bartholow 

OZ(ENA.     (See  also  Catarrh,  Nasal.) 

In  chronic  nasal  catarrh,  if  the  mucous  membrane  is 
destroyed  by  ulcerations,  and  caries  of  the  bones  has  occurred, 
the  case  is  then  called  ozoena. 

The  morbid  process  extends  through  the  nasal  passages  and 
into  neighboring  cavities.  The  discharge  consists  of  a  greenish, 
offensive  pus,  or  of  scales  taking  the  form  of  casts  of  the  bones 
which  are  also  offensive  from  decomposition  (Bartholow). 

The  disease  is  very  obstinate  and  hard  to  cure.  The  follow- 
ing prescriptions  may  be  tried: 

R     Sodii  biboratis 

Ammonii  chloridi — aa gr.  xx. 

Potassii  permanganatis gr.  x. — M. 

Sig.:  To  be  dissolved  in  one  pint  of  tepid  water  and  used  thrice 
daily  with  a  syringe  or  douche.  Sajous. 

R     Extracti  hydrastis  fluidi Sij- 

Sig.:  Five  minims  in  water  three  times  daily.  Also  add  one 
teaspoonful  to  half  a  pint  of  tepid  water  and  use  as  a  lotion  for  syr- 
inging the  nares.  Bartholow. 


376  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ONANISM.     (See  Masturbation.) 
OXYURIS  VERMICULARIS. 

Called  also  thread  worm  from  its  resemblance  to  pieces  of 
ordinary  white  sewing  thread,  also  seat -worm  from  its  habitat,  is 
frequent  in  childhood  and  not  infrequent  in  the  adult  (Smith). 

Size. — The  length  of  the  male  oxyuris  is  about  one-fourth  of 
an  inch;  that  of  the  female  about  one-half  inch.  They  are  cylin- 
drical and  taper  to  both  extremities.  - 

Habitat. — The  habitat  of  the  oxyuris  is  the  large  intestine 
of  man,  especially  the  rectum,  and  they  insinuate  themselves  into 
the  folds  of  the  mucous  membrane  and  shin  at  the  margin  of  the 
anus.  They  migrate  into  the  vagina  and  upward  into  the  large 
intestine  and  lower  part  of  the  ileum  in  great  numbers.  The 
eggs  are  oval,  each  female  containing  about  10,000.  All  their 
stages  of  development  take  place  within  the  intestinal  canal. 
The  ova  enter  by  means  of  the  food  or  directly  through  personal 
contamination  (Bartholow). 

Symptoms. — They  excite  by  their  presence  in  the  rectum  an 
intolerable  itching,  sometimes  severe  pain,  tenesmus  usually,  and 
these  sensations  are  propagated  to  the  genito- urinary  organs. 
The  itching  is  most  troublesome  at  night,  when  warm  in  bed. 
The  stools  are  usually  relaxed,  fetid  and  coated  with  mucous. 
The  skin  about  the  anus  is  reddened.  Various  reflex  phenomena 
are  induced  by  the  irritation  of  the  worm  such  as  epilepsy, 
chorea,  catalepsy,  etc.  (Bartholow). 

Treatment, — Santonine  aided  by  calomel  should  be  first 
given.  As  soon  as  this  has  acted,  the  bowel  should  be  irrigated 
by  a  weak  decoction  of  quassia  or  of  aloes.  If  the  vagina  is  in- 
fested, it  must  be  irrigated  with  the  same  solution.  The  next 
step  consists  in  carefully  sponging  out  all  the  folds  and  crevices 
of  the  anus  and  perineum  and  the  external  genitals  also  with  a  one 
per  cent,  solution  of  carbolic  acid.  Vix  has  found  water  and 
castile  soap  to  be  the  most  effectual  enema.  A  variety  of  sub- 
stances administered  by  injection  ^vill  speedily  destroy  thread- 
worms. Thus  a  teaspoonful  of  common  salt  in  solution,  or  a 
drachm  of  sesqui -chloride  of  iron  in  a  pint  of  water  are  very  ef- 


OXYURIS    VERMICULARIS OPACITIES    IN    EYE.  377 

ficacious;  so  is  lime  water,  solution  of  alum  and  in  fact  any  sub- 
stance which  coagulates  the  albumen  of  the   worms   (Bartholow. 
and  Ringer). 

PRESCRIPTIONS  FOR  OXYURIS  VERMICULARIS. 

jfc     Santonini gr-  X1J- 

Olei   theobromse 3J • — M- 

Ft.  suppositoriae  no.  iv. 
Sig. :     One  at  bed  time  introduced  into  the  rectum.— Hartshorne. 

Jfc     Tinct.  rhei £&•  ni- 

Tinct.  zingiberis ..gtt.  j. 

Magnesii  carbonatis 5 v. 

Aquaa 3iij-— M. 

Sig.:     This  dose  should  be  taken  three  or   four   times   daily   ac- 
cording to  the  effect  on  the  bowels.  —Martin. 

R     Sodii   chloridi 3*. 

Aqua3  svi.— M. 

Ft.  sol. 
Sig.:     To  be  injected  by  the  rectum.  — Eillard. 

R     Tinct.  ferri  chloridi §ss. 

Aquae Oj.— M. 

Sig. :     One  fourth  to  one  third  as  a  rectal  enema.  —Ringer. 

OPACITIES  IN  EYE. 

The  opacity  is  a  cloudiness  in  the  transparent  media  of  the 

6ye'  Causes.— The  causes  are  various.     They  result  from  ulcera- 
tions, burns,  injuries,  inflammation  from  excision  of  a  pterygium, 

etc 

Discovery.— To  discover  a  very  faint  opacity,  one  must  use 

oblique  illumination  in  a  dark  room  or  examine  with  the  ophthal- 
moscope and  feeble  light.  A  plain  mirror  having  behind  it  a 
convex  glass  of  three  inches  focus  will  do  the  best  service.  Dis- 
tant vision  is  always  more  disturbed  by  faint  opacities  than  near 
vision  A  well  defined  opacity  partially  covering  the  pupil  is 
much  less  damaging  to  vision  even  if  dense,  than  a  famt  haze 
with  filmy  edges  (Noyes). 


378  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

Treatment. — The  more  recent  the  opacities  the  more  likely 
are  they  to  improve.  So  long  as  blood  vessels  remain  in  their 
vicinity  the  improvement  will  continue.  The  restorative  action 
will  go  on  for  .months.  The  treatment  consists  in  stimulating 
applications.  The  most  serviceable  are:  very  finely  powdered 
calomel  dusted  daily  into  the  eye  and  which  is  esj)ecially  suited 
to  children;  ointment  of  yellow  oxide  of  mercury  (gr.  ij-x  to  the 
o.  j.)  to  be  used  every  night,  or  once  in  two  or  three  nights,  ac- 
cording to  susceptibility:  astringent  drops  in  various  strengths,  as 
sulphate  of  zinc,  alum,  sulphate  of  cadmium,  tannin  in  glycerine 
(5.  ss.  to  o.  j.)  tincture  of  opium  diluted  1  to  10,  solution  of 
iodide  potassium,  1  to  3;  common  salt  1  to  5  or  20;  hot  fomenta- 
tions: powdered  sugar,  molasses,  etc.  The  object  is  to  irritate 
and  cause  hyperemia,  not  to  last  longer  than  a  patient  can  toler- 
ate. Opacity  will  grow  fainter  for  at  least  a  year.  When  no 
further  absorption  is  possible  and  a  dense  opacity  exists,  two 
proceedings  remain,  and  they  are  often  combined,  namely,  iridec- 
tomy and  tattooing.  An  artificial  pupil  should,  as  a  rule,  never 
be  made  during  the  recent  stage  of  an  opacity  unless  very  dense 
and  extensive.  When  the  pupil  is  covered  or  the  iris  is  pro- 
lapsed and  a  marginal  part  of  the  cornea  is  more  or  less  clear,  an 
iridectomy  will  be  in  place.  The  spot  at  which  a  pupil  is  to  be 
placed  is  frequently  not  a  matter  of  discretion  because  there  may 
be  only  one  clear  region.  If  a  choice  is  possible  the  lower  seg- 
ment of  the  cornea  is  to  be  preferred  to  the  upper.  Very  dense 
opacities  which  are  a  blemish  both  to  sight  and  to  personal  ap- 
pearance  may  be  tattooed  with  India  ink.  The  fine  and  expen- 
sive quality  of  ink  is  to  be  used.  A  bit  of  the  ink  paste  equal 
to  the  size  of  the  spot  to  be  colored  is  placed  upon  the  cocanized 
cornea.  Numerous  and  rather  forcible  pricks  with  a  bunch  of 
needles  driven  obliquely  in  various  directions  will  force  the  ink 
under  the  epithelium,  and  if  it  be  thick  enough  one  sitting  may 
be  suificient  (Xoyes). 

0VER=W0RK, 

Treatment. — When  there  is  sleeplessness  caused  by  worry  or 
over-work,  or  that  occurring  at  the  menopause,  or  from  men- 
strual disturbances,  the  bromide    of    potassium  in  twenty   grain 


(ESOPHAGEAL    OBSTRUCTION.  379 

closes  at  night  is  invaluable.  A  drop  of  laudanum  with  two  of 
tincture  of  mix  vomica,  three  or  four  times  a  day,  will  relieve  the 
distressing  symptoms  of  hysterical  women  or  nervous  over- 
worked anxious  men.  Persons  in  broken  health  from  over-work 
are  benefited  by  *Sr  to  -sV  of  a  grain  of  phosphorus,  thrice  daily 
for  several  months.  A  sitz-bath  for  ten  minutes  at  70°  to  80°  on 
return  from  business  tired  and  irritable,  and  one-half  hour  before 
dinner  is  highl}T  beneficial  (Ringer). 

(ESOPHAGEAL  OBSTRUCTION. 

As  its  name  implies,  is  an  obstruction  of  the  oesophagus  in 
any  part  of  the  tube  from  whatever  cause. 

Causes. — When  a  patient  complains  of  difficulty  in  swallow- 
ing, or  rather  the  difficulty  in  passing  food  onward  down  the 
oesophagus  after  the  act  of  swallowing  has  been  performed,  and 
of  its  subsequent  return  into  the  mouth,  the  surgeon  in  looking 
for  the  cause  should  first  think  of  thoracic  aneurism,  then  of 
cancer  of  some  portion  of  the  tube,  and  lastly  of  syphilitic  or 
simple  ulceration.  He  should  also  always  inquire  into  the  his- 
tory of  the  case,  as  to  whether  the  patient  sustained  any  local 
injury  from  the  swallowing  of  a  foreign  body,  of  boiling  water, 
or  of  corrosive  fluid.  If  injury  and  aneurism  can  be  excluded, 
there  is  little  doubt  that  the  true  cause  is  cancer  (Bryant). 

Symptoms. — So  long  as  solid  food  passes,  the  patient  is 
hardly  aware  of  any  obstruction  existing,  and  seldom  consults  a 
physician.  The  first  symptom  that  attracts  notice  is  the  regurgi- 
tation of  food.  As  the  disease  advances  some  sign  of  ulceration 
may  appear,  such  as  the  discharge  of  pus  or  blood,  which  usually 
comes  up  with  the  regurgitated  food,  and  when  this  occurs  there 
is  no  better  indication  of  the  presence  of  ulcerative  action.  If 
the  patient  be  middle-aged,  the  probabilities  of  the  disease  being 
cancer  are  very  strong;  and  should  there  be  any  local  thickening 
behind  the  larynx  or  glandular  enlargement,  the  probabilities 
are  enhanced.  The  following  case  which  occurred  in  a  patient 
of  the  writer  illustrates  the  above  very  forcibly.  The  patient, 
aged  53,  was  dying  from  starvation  caused  by  inability  to  swal- 
low on  account  of  obstruction  of  the  oesophagus.     By  question- 


380  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ing  it  was  learned  that  the  trouble  had  commenced  nine  months 
before.  There  was  no  history  of  injury.  Upon  examination 
there  was  found  a  thickening  behind  the  larynx  and  enlargement 
of  contiguous  lymphatic  glands.  All  liquids  or  solids  swallowed 
by  the  patient  were  immediately  returned  into  the  mouth  together 
with  pus  and  stringy  mucus.  The  patient  died  seven  days  after 
the  examination.  The  autopsy  showed  almost  a  complete  closure 
of  the  oesophageal  tube  in  its  upper  third  due  to  cancer. 

Treatment. — The  treatment  by  dilatation  must  be  looked 
upon  as  a  dangerous  measure,  except  when  the  stricture  is  of  the 
cicatricial  form,  the  passage  of  an  instrument  in  cancerous  or  any 
ulcerative  disease  being  likely  to  hasten  the  fatal  termination  by 
causing  perforation  of  the  ulcer  into  the  air  passages  or  pleura. 
In  these  cases  fluid  nourishment  should  be  taken.  When 
swallowing  becomes  impossible,  a  fine  flexible  tube  may  be  passed 
through  the  stricture.  The  powers  of  the  patient  may  be  kept 
up  by  nutritious  enemata.  When  all  these  means  fail,  the  ques- 
tion of  opening  the  stomach  by  an  operation  must  be  enter- 
tained. Billroth  recently  has  cut  down  upon  the  oesophagus  and 
excised  the  cancerous  growth  but  without  success;  the  operation 
is  commended  to  our  consideration  only  by  the  eminence  of  the 
surgeon  who  performed  it  (Bryant). 

PALPITATION  OF  THE  HEART. 

Is  a  functional  disturbance  of  the  organ  characterized  by 
increased  rapidity  of  movement,  with  more  or  less  irregularity  of 
rhythm  (Bartholow). 

Causes. The  heart  has  a  power  of  independent  motion, 

motor  apparatus,  but  it  also  receives  force  from  the  great 
centres.  To  maintain  the  movement  at  a  uniform  rate,  there  is  a 
regulator  apparatus,  designed  to  prevent  overaction  or  to  inhibit. 
Besides  this  mechanism  for  evolving  force  and  applying  it  so  as 
to  produce  uniform  results,  the  action  is  affected  by  the  state  of 
the  vessels,  by  the  density  of  the  blood,  by  the  movements  of  the 
respiratory  organs,  and  by  the  functions  of  animal  life.  Hence, 
to  maintain  the  action  of  the  heart,  there  are :  1.  A  motor 
apparatus — motor    ganglia  —  situated  in    the   substance    of   the 


PALPITATION    OF    THE    HEART.  381 

heart.  2.  Excitors  of  activity,  branches  from  the  cervical  sym- 
pathetic, and  also  from  the  spinal  cord,  irritation  of  which  in- 
creases the  movements  of  the  heart.  To  regulate  the  movements 
of  the  heart,  there  are :  1.  The  pneumogastric,  irritation  of 
which  may  arrest  the  heart  in  diastole.  2.  The  depressor  nerve 
of  Ludwig,  which  acts  by  dilating  the  blood  vessels.  The 
fibres  of  the  sympathetic,  dilator  and  constrictor,  affect  the  work 
of  the  heart  by  increasing  or  lessening  the  tension  at  the  peri- 
phery. The  direct  cause  of  palpitation  is  over- stimulation  of  the 
cardiac  muscle  or  the  excitability  from  functional  derangement 
of  the  pneumogastric,  or  cardiac  ganglia,  which  is  either  induced 
by  direct  or  reflex  causes.  Muscular  exercise,  breathing  rarefied 
air,  as  in  the  ascent  of  mountains,  and  blows  on  the  epigastrium 
may  cause  it.  Mechanical  interference  with  the  movements  of 
the  organ,  as  contracted  chest,  thoracic  effusions,  tumors  of  the 
mediastinum,  flatulence,  distension  of  the  stomach  and  atheroma 
of  the  arterial  system  generally  may  induce  it.  Moral  and  emo- 
tional causes,  as  grief,  hope,  anxiety,  fear,  excessive  mental 
effort,  etc.,  increase  the  action  of  the  heart.  Various  reflex 
troubles  have  the  same  effect,  such  as  uterine  disease,  gastralgia, 
worms,  etc.  Palpitation  is  a  very  frequent  symptom  in  states  of 
debility  or  anaemia.  The  cardiac  ganglia  are  rendered  irritable 
by  the  excessive  use  of  tea,  coffee,  tobacco  and  spirits.  Sexual 
excesses,  enervating  habits,  diabetes,  sudden  shock  or  fright, 
chorea  or  derangements  of  the  digestive  organs  may  cause  it. 
Gout,  chronic  disease  of  the  liver  and  Grave's  disease  may  be  ac- 
companied by  palpitation  (Bartholow  and  Loomis).  Palpitation 
may  accompany  organic  cardiac  disease  (DaCosta). 

Symptoms. — The  normal  cardiac  impulse  is  so  slight  that  the 
motion  is  not  percejDtible,  unless  the  hand  be  applied  to  the 
precordial  space.  Whenever  a  person  becomes  sensible  of  the 
beating  of  his  own  heart,  he  may  be  said  to  have  cardiac  palpi- 
tation. The  cardiac  impulse  is  unnaturally  strong,  and  the 
action  of  the  heart  unnaturally  rapid,  which  may  be  irregular  or 
intermitting.  Sometimes  there  is  a  loss  of  three  or  four  beats 
which  causes  a  sense  of  oppression,  or  even  of  impending  death. 
Palpitation  may  be  accompanied  by  a  choking,  paroxysmal, 
fluttering  sensation.     The  heart- sounds  may    be   audible  to  the 


382  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

patient  when  lie  lies  on  his  left  side.  There  may  be  precordial 
pain  or  anxiety.  The  carotids  throb.  The  attack  may  last  from 
a  few  minntes  to  some  hours,  or  a  day.  There  is  dyspnoea.  The 
heart  seems  almost  to  turn  over,  to  rise  up  into  the  throat.  The 
patient  cannot  lie  down.  There  may  be  vertigo,  faintness  and 
flashes  of  light.  The  face  may  be  pale  or  flushed.  Speech  is 
difficult.  At  the  end  of  the  paroxysm  a  quantity  of  pale,  limpid 
urine  is  usually  passed.  Dr.  Cotton  reported  a  case  in  which  the 
pulsations  were  240  per  minute,  and  ceased  on  the  evacuation  of 
of  a  tape -worm  (Bartholow  and  Loomis). 

Differential  Diagnosis. — Cardiac  palpitation  independent  of 
organic  disease  of  the  heart  may  be  mistaken  for  cardiac  palpita- 
tion depending  upon  organic  cardiac  disease.  The  former  comes 
on  suddenly  and  is  not  constant;  the  latter  comes  on  slowly  and 
is  persistent.  In  functional  palpitation,  all  the  physical  signs  of 
organic  cardiac  disease  are  absent.  Palpitation  of  organic  heart 
disease  is  increased  by  exercise  (Loomis). 

Prognosis. — Is  always  good  in  functional  cardiac  palpitation, 
but  may  cause  the  patient  great  uneasiness  (Loomis). 

Treatment. — Discover  and  remove  the  cause.  Tea,  coffee, 
tobacco  and  alcoholic  stimulants  must  be  given  up.  Errors  of 
digestion,  reflex  disturbances  and  curable  diseases  must  be  cor- 
rected at  once  or  cured.  Anaemic  subjects  should  take  iron 
in  large  doses  for  a  long  period.  The  body  should  be  sponged 
night  and  morning  in  cold  water.  In  the  absence  of  any  explan- 
ation of  the  paroxysms,  the  presence  of  a  tape  worm  maybe  sus- 
pected. For  the  immediate  relief  of  the  attack,  there  is  no 
remedy  so  efficient  as  the  hypodermic  injection  of  morphia.  If 
the  surface  is  pale  and  the  extreme  vessels  contracted,  inhalation 
of  nitrite  of  aruyl  (two  to  three  drops)  affords  prompt  relief. 
The  application  of  the  ice-bag  to  the  precordial  region  is  an 
effective  means  of  quieting  the  heart.  The  galvanic  current, 
from  ten  to  thirty  elements,  passed  through  the  pneumogastric 
and  cervical  ganglia  of  the  sympathetic,  often  gives  great  relief. 
Chloral,  the  bromides,  camphor,  asafcetida,  and  valerian  are 
sometimes  useful.  Digitalis  should  never  be  given  in  purely 
nervous  cardiac  palpitation.     The  physician  should  assure  the 


PAKALYSIS.  383 

patient  that  there  is  no  danger  attending  the  paroxysm  of  func- 
tional cardiac  palpitation  (Bartholow  and  Loomis). 

PARALYSIS. 

Is  the  loss  of  muscular  contractility,  and,  as  a  consequence, 
of  the  power  of  motion.  The  term  is  also  applied  to  the  loss  of 
sensibility.  The  former  is  motor  and  the  latter  sensory 
paralysis. 

Paralysis  is  not  a  disease,  but  a  symptom.  A  slight  incom- 
plete paralysis  is  called  paresis. 

Origin  and  Extent. — Paralysis  is  nearly  always  of  nervous 
origin.  It  may  be  general  or  partial.  It  may  affect  the  majority 
of  the  muscles  of  the  frame,  or  be  limited  to  one  muscle.  It  may 
be  strictly  confined  to  one  side  (hemiplegia),  or  exist  solely  in 
the  lower  half  of  the  body  (paraplegia).  It  may  be  complete 
or  incomplete.  It  may  come  on  rapidly  or  slowly  (DaCosta  and 
Flint). 

Causes. — Paralysis  may  be  neuropathic  or  myopathic.  A 
niyojDathic  paralysis  depends  on  a  primary  morbid  condition  of 
the  muscles  paralyzed.  Neuropathic  paralysis  depends  on  either 
a  morbid  condition  of  the  nerve  centres  or  nerves.  The  neuro- 
pathic is  divided  into  central  and  peripheral  paralysis.  Central 
paralysis  depends  on  morbid  conditions  seated  in  either  the 
brain  or  spinal  cord,  and  are  divided  into  cerebral  and  spinal. 
Peripheral  paralysis  depends  on  morbid  conditions  affecting  the 
nerves  at  any  point  between  their  terminations  and  their  central 
connections  with  either  the  brain  or  spinal  cord. 

The  causes  may  be  thus  summed  up  : 

1.  Paralysis  due  to  a  lesion  or  any  morbid  condition  of  the 
nervous  centres  as  hemorrhage  into  or  softening  of  the  central 
nervous  textures,  and  certain  diseases  of  the  brain  and  spinal 
cord.  To  this  class  must  be  added  the  functional  palsies  which 
depend  upon  a  functional  derangement  of  the  great  centres  of 
innervation,  such  as  hysterical  paralysis,  and  that  occurring  after 
overwork  or  excesses,  and  from  nervous  exhaustion. 

2.  Paralysis  due  to  a  lesion  in  the  course  of  a  nerve,  such 
as  a  wound  or  compression.     Pals}'  from  this  cause  is  local,  and 


384  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  apt  to  show  morbid  nutritive  changes  in  the  affected  part,  such, 
as  glossy  fingers  and  swollen  joints,  and  to  be  associated  with 
pain. 

8.  Paralysis  due  to  an  affection  of  the  nerves  at  their  ex- 
tremities, such  as  exposure  to  cold.  Peripheral  palsies  lead 
quickly  to  atrophy  of  the  muscles. 

4.  Paralysis  due  to  reflex  action,  such  as  irritation  of  the 
dental  nerves  in  teething  children,  disorders  of  the  intestines 
both  in  adults  and  in  children,  or  disease  of  the  bladder,  urethra, 
prepuce,  uterus,  lungs,  plura,  or  irritation  of  the  nerves  of  the 
skin.  In  these  cases,  the  paralysis  is  produced  through  the  reflex 
centres,  which  reflect  the  irritation  communicated  to  them  to 
parts  healthy  in  themselves.  How  else  can  a  wound  of  a  nerve 
on  one  side  of  the  body  lead  to  palsy  on  the  other  ?  Keflex 
paralysis  is  rarely  of  long  duration. 

5.  Paralysis  due  to  serious  interference  with  the  circulation 
as  after  the  ligation  of  a  large  artery. 

6.  Paralysis  due  to  a  morbid  state  of  the  muscles,  as  certain 
forms  of  rheumatic  palsy  and  of  muscular  atrophy. 

7.  Paralysis  due  to  the  presence  of  poison  in  the  system, 
such  as  lead,  arsenic,  mercury,  alcohol,  sulphuret  of  carbon,  ma- 
larial poison,  and  the  poisons  of  rheumatism,  gout  and  acute 
diseases  (DaCosta). 

Condition  of  Paralyzed  Parts. — The  nutrition  and  secretion 
are  disturbed  and  the  circulation  is  sluggish.  They  are  fre- 
quently swollen  and  cedematous,  the  pulse  is  weaker  than  in  the 
sound  members,  and  the  sensation  is  impaired,  the  nails  grow 
slowly,  so  do  the  hairs,  the  perspiration  is  defective,  the  skin 
feels  cold  and  is  prone  to  break.  The  muscles  may  be  relaxed 
or  rigid,  and  diminished  in  size. 

The  mode  in  which  palsies  are  investigated  at  the  bed  side. 
We  must  notice  the  size,  appearance  and  feel  of  the  stricken  part. 
Then  we  test  the  sensibility  to  contact,  to  tickling,  to  pinch- 
ing, to  cold  and  to  heat;  we  measure  the  tactile  sense  by  the 
sesthesiorneter  and  note  the  reflex  movements.  We  next  contrast 
the  muscles  and  their  motion  with  the  healthy  side.  We  test  the 
power  by  the  grasp  and  by  other  means.     But  the  most  valuable 


PARALYSIS.  385 

agent  to  judge  of  the  state  of  the  muscle  is  electricity.  We 
should  compare  the  contractions  of  the  sound  side  with  those  of 
the  diseased  (DaCosta). 

Differential  Diagnosis. — There  are  certain  points  of  difference 
in  the  effects  of  cerebral,  spinal  and  peripheral  paralysis.  In 
cerebral  paralysis  the  reflex  excitability  of  the  affected  muscles 
is  retained  and  may  be  increased.  The  electro -muscular  con- 
tractility is  intact  in  cerebral  palsies.  The  muscles  do  not 
speedily  become  atrophied.  The  cutaneous  sensibility  is  often 
undiminished.  In  spinal  paralysis,  the  paralyzed  muscles  do 
not  retain  their  reflex  and  electrical  excitability;  but  there  are 
exceptions  to  this.  Sensibility  may  be  retained,  diminished  or 
lost.  There  may  or  may  not  be  trophic  disturbances.  In  pe- 
ripheral paralysis  the  reflexes  are  generally  diminished.  The  af- 
fected muscles  undergo  rapid  trophy,  and  the  nerves  and  muscles 
take  on  the  action  of  degeneration.  Peripheral  paralysis  may 
be  the  result  of  syphilis  or  diphtheria.  In  all  cases  of  paralysis 
we  must  get  the  history  of  the  case   (DaCosta  andFlint). 

" Paralysis  from  Commotion.'''' — Cases  in  which  paralysis 
occurs  after  a  variable  period  dating  from  railway  accidents, 
have  been  described  especially  by  Erichsen.  These  cases  have 
been  considered  as  important  in  a  medico -legal  point  of  view. 

GENERAL  PARALYSIS. 

Exclusive  of  general  cerebral  paralysis,  general  paresis,  or 
paralysis  of  the  insane,  general  palsy  dependent  upon  morbid 
conditions  of  the  brain  is  rare. 

Causes. — It  may  be  a  result  of  two  attacks  of  hemiplegia, 
the  first  attack  affecting  one,  and  the  second  the  other  side. 
Hemorrhage  into  the  central  portions  of  the  pons  or  bulb  may 
give  rise  to  double  hemiplegia,  or  general  palsy.  In  the  great 
majority  of  cases  general  paralysis  is  spinal.  The  seat  in  the 
spinal  cord  is  to  be  inferred  whenever  cranial  nerves  are  not  in- 
volved and  there  are  no  symptoms  denoting  cerebral  disease. 
General  spinal  paralysis  is  incident  to  inflammatory  and  struc- 
tural affections  of  the  spinal  cord  and  its  meninges.  In  rare  in- 
stances it  follows  diphtheria,  and  is  sometimes  connected  with 


386  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

hysteria.     It  may  be  caused  by  exhaustion  and  exposure  to  cold. 

Spinal  hemiplegia,  with  motor  jmralysis  on  one  side  and 
anaesthesia  on  the  opposite  side,  probably  always  implies  a  lesion 
limited  to  the  half  of  the  cervical  portion  of  the  cord  on  the  side 
of  the  motor  paralysis. 

Paralysis  may  affect  the  upper  limb  of  one  side  and  the 
lower  limb  of  the  other  side;  and  may  be  produced  by  lesions 
situated  at  the  crossing  of  the  pyramids  in  the  bulb. 

In  hemiplegia  or  one  sided  palsy,  the  face  may  be  paralyzed 
on  the  same  side  as  the  rest  of  the  body,  and  the  reason  of  this 
lies  in  the  fact  that  the  facial  nerves  decussate.  Should,  then, 
the  lesion  be  situated  in  the  brain  above  this  crossing,  both  face 
and  body  are  paralyzed  on  the  opposite  side  to  the  diseased  spot. 
Should,  however,  the  lesion  involve  the  facial  nerve -fibres  at  a 
point  below  or  after  the  decussation,  there  will  be  paralysis  of 
the  face  on  one  side;  and  of  the  limbs  on  the  other.  This  is 
cross  paralysis,  and  is  always  indicative  of  a  lesion  of  the  pons 

Varolii. 

Paralysis  may  come  on  suddenly  or  gradually.  A  sudden 
paralysis  almost  always  has  its  origin  in  an  apopletic  effusion, 
cerebral  embolism,  and  softening.  A  gradual  development  of 
palsy  indicates  some  chronic  cerebral  disorder,  such  as  softening, 
a  tumor,  or  any  affection  compressing  the  nervous  substance. 

Monoplegia  is  a  paralysis  of  a  muscle  or  a  set  of  muscles,  of 
one  limb,  or  of  one  side  of  the  face. 

PARAPLEGIA. 

Is  paralysis  of  the  lower  half  of  the  body. 

Causes. — Its  almost  invariable  cause  is  a  lesion  of  the  spinal 
cord.  Exhaustion,  exposure  to  cold,  sexual  excesses,  hysteria, 
diphtheria,  syphilis,  poisons,  small  clot  in  the  pons,  injury  to 
cord,  spina-bifida,  tumors,  shock  and  concussion  of  the  spine  are 
the  principal  causes  (DaCosta,  Flint  and  Loomis). 

Treatment. — Of  remedies  having  direct  reference  to  the  para- 
lysis, electricity  holds  the  first  rank.  When  the  paralysis  is  due 
to  diseases  involving  innammation,  we  must  not  apply  the  cur- 
rents until  the  proper  time.     Frictions,  massage,  kneading  and 


PAEALYSIS PARAPLEGIA.  387 

stimulating  liniments  are  useful.  Of  drugs,  strychnia  or  nux 
vomica  and  phosphorus  are  to  he  recommended.  The  cause  in 
each  should  he  removed  if  possible.  Strychnia  is  contraindicated 
in  the  cases  of  hemiplegia  when  the  injury  to  the  brain  or  cord 
has  been  recent.  It  generally  does  no  good,  but  harm,  when  the 
paralyzed  muscles  are  rigid.  In  local  paralysis,  the  solution  of 
strychnia  should  be  thrown  into  the  substance  of  the  paralyzed 
muscles  (Bartholow  and  Flint). 

PEDICULI.    (See  Lice). 

PEMPHIGUS. 

Is  a  skin  disease  characterized  by  an  eruption  of  bullae. 
Bullae  differ  from  vesicles  onry  in  their  size.  They  resemble 
large  blisters.     Pemphigus  is  the  typical  bullous  disease. 

Description. — This  is  a  comparatively  rare  affection;  it  is 
more  common  in  children  than  adults.  It  appears  in  very  large 
vesicles  or  bullae,  surrounded  by  a  slight  zone  of  erythematous 
redness.  The  blebs  occur  in  crops  and  look  like  small  blisters 
filled  with  serum.  They  are  not  met  with  on  the  scalp;  where 
there  are  few  bullae  we  generally  find  them  on  the  ankle,  or  on 
the  hand.  The  disorder  may  be  acute  or  chronic.  It  occurs 
mostly  in  persons  of  feeble  constitution.  Relapses  are  frequent. 
Pemphigus  may  be  produced  by  the  administration  of  iodide  of 
potassium,  or  by  syphilis. 

Syphilitic  Pemphigus. — Is  mainly  met  with  on  the  soles  of 
the  feet  and  the  palms  of  the  hands  of  the  newly  born  syphilitic 
children.  The  bullae  vary  in  size  from  that  of  a  pea  to  a  walnut 
(Anderson  and  DaCosta). 

Causes. — Are  unknown. 

Treatment. — Tonics  must  be  given,  and  of  these  the  most 
important  are  quinine  and  arsenic.  Local  treatment  is  effective. 
The  bullae,  if  tense,  may  be  opened,  and  afterwards  dusted  with 
a  soothing  powder.    Baths  are  highly  recommended  (Anderson). 


388  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PRESCRIPTIONS  FOR  PEMPHIGUS. 

R     Sodii  biboratis gss. 

Tragacanth 3j . 

Spiritus  rectificati 3ij . 

Gly  cerinse giv. 

Aqua?  destillatas giss. — M. 

Sig. :     Smear  a  little  over  the  excoriated  part  and  allow  it  to  dry. 

— Anderson. 

R     Pulveris  lycopodii gj.. 

Sig. :     Use  as  a  dusting  powder  after  the  bullae  are  cut.     Then 
use  zinc  ointment,  and  then  use  the  following  : 

R     Argenti  nitratis gr.  iij.-iv. 

Adipis 5j. — M. 

Ft.  ungt. 
Sig. :     Apply  locally.  — Tilbury  Fox. 

PERICARDITIS. 

Is  an  inflammation  of  the  serous  membrane  (the  pericard- 
ium) investing  the  heart.  The  inflammation  may  be  circum- 
scribed or  diffused,  acute  or  chronic. 

Causes. — Primary  pericarditis  may  arise  from  injuries  to 
the  pericardium,  or  from  cold.  Secondary  pericarditis  is  more 
common,  and  is  due  to  two  causes:  1.  To  an  extension  of  in- 
flammation from  neighboring  parts,  as  in  pneumonia,  left  pleu- 
risy, pulmonary  tuberculosis,  caries  of  the  sternum  or  ribs,  aneu- 
rism of  the  aorta,  endocarditis,  etc.  2.  To  the  rheumatic  dyscra- 
sia.  It  also  occurs  in  the  course  of  Bright's  disease,  acute 
infectious  diseases,  as  scarlet  fever,  smallpox,  typhus  and  typhoid 
fever,  and  of  syphilis  and  chronic  alcohoiismus.  It  is  of  most 
frequent  occurrence  in  connection  with  acute  articular  rheuma- 
tism, Bright's  disease  and  pneumonia  (Bartholow  and.  Loomis). 

Symptoms. — Pericarditis  occurs  most  frequently  between  the 
ages  of  15  and  30.  The  two  prominent  rational  symptoms  are 
pain  in  the  precordial  region,  and  palpitation.  The  pain  may 
also  involve  the  brachial  plexus  and  extend  down  the  left  arm. 
It  is  sometimes  very  slight,  again  it  is  sharp  and  lancinating. 
With  the  pain  there  are  palpitation,  a  dry  irritable  cough,  and  a 
sense  of  constriction    over  the    whole  chest,  with   more  or  less 


PERICARDITIS.  389 

dyspnoea.  The  cough  is  suppressed  and  forced  breathing  in- 
creases the  pain.  If  there  is  much  effusion  the  patient  assumes 
the  half  sitting  posture.  The  face  is  often  livid  and  has  the 
appearance  of  suffering  and  anxiety.  At  first  the  pulse  is  full 
and  strong,  and  more  or  less  accelerated.  When  there  is  much 
effusion  it  is  irregular,  intermitting,  and  strongly  dicrotic. 
Pyrexia,  anorexia,  and  debility  are  present.  There  may  be 
jaundice,  headache,  and  delirium.  The  pain  and  soreness 
usually  diminish  when  the  fluid  effusion  takes  place;  and  now 
the  patient  has  a  sensation  of  oppression  in  the  cardiac  region, 
with  a  tendency  to  syncope  on  moving.  If  there  be  much  effusion 
it  will  cause  dyspnoea,  feebleness  of  the  voice,  or  even  aphonia 
and  dysphagia.  Cyanosis  and  turgescence  of  the  cervical  veins 
are  sometimes  marked,  due  probably  to  pressure  on  the  auricles 
and  the  venae  cavse. 

Singultus  (hiccough)  may  be  produced  by  pressure  on  the 
phrenic  or  branches  of  the  pneumogastric  nerve.  As  pericarditis 
is,  in  the  great  majority  of  cases,  associated  with  acute  articular 
rheumatism,  Bright^  disease,  pleurisy  or  pneumonia,  it  is  imper- 
ative to  make  a  physical  examination  of  the  heart,  when  these 
diseases  exist  (Flint  and  Loomis). 

Physical  Signs. — Are  most  important.  They  vary  in  the  dif- 
ferent stages  of  the  disease.  In  the  first  stage,  inspection  and 
palpation  show  an  irritable,  turbulent,  forcible,  and  sometimes 
irregular  action  of  the  heart.  Palpation  gives  a  friction-fremi- 
tus  in  a  few  cases  for  a  brief  period.  This  vibration  of  the  chest 
wall  is  caused  by  the  rubbing  together  of  the  roughened  surfaces 
of  the  pericardium.  To  develop  this  sensation,  firm  pressure 
must  be  made  in  the  intercostal  space  with  the  finger  tips;  as  the 
whole  hand  laid  on  the  chest  may  not  detect  it;  it  is  a  rough, 
jarring,  rasping  sensation.  On  auscultation  the  first  positive 
physical  sign  of  pericarditis  is  the  pericardial  or  cardiac-friction 
murmur  which  is  jn'oduced  by  the  rubbing  together  of  the  two 
surfaces  roughened  by  exudations.  This  friction  murmur  makes 
the  impression  on  the  ear  of  scraping,  grating,  creaking  and 
churning.  This  cardiac  friction  murmur  will  be  increased  in 
intensity  when  the  body  is  bent  forward,  and  also  by  a  full  in- 
spiration.    It  is  superficial  in  character,  and  is  double,  one  sound 


390  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  produced  by  the  systolic  and  the  other  by  the  diastolic  cardiac 
movements.  The  friction  murmur  and  friction  fremitus  occur 
within  the  first  two  days,  and  may  persist  for  several  days.  A 
friction  murmur,  if  ever  wanting  in  the  first  stage  of  jDericarditis, 
is  j3resent  so  generally,  that  we  are  warranted  in  basing  an  ex- 
clusion of  the  disease  on  its  absence.  The  murmur  is  almost 
pathognomonic  taken  in  connection  with  the  symptoms  and  his- 
tory. 

In  the  second  or  stage  of  effusion  the  friction  murmur  disap- 
pears after  considerable  effusion  of  liquid  has  taken  place,  but  it 
may  continue  in  this  stage  and  also  in  the  stage  of  convalescence. 
Inspection  now  shows  diminished  respiratory  movements  over 
the  precordial  space  and  an  arching  forward  of  the  precordial 
region  with  abolition  of  the  intercostal  depressions.  Palpation 
shows  the  apex-heat  to  be  weakened,  to  be  raised  to  the  fourth, 
intercostal  space  and  to  be  carried  to  the  left  as  far  as,  or  even  be- 
yond the  line  of  the  nipple.  Percussion  snows  an  increased  area 
of  dullness  or  flatness  in  the  precordial  region.  The  form  of  this 
dullness  is  triangular  or  pyramidal,  with  the  base  of  the  pyra- 
mid below  and  the  apex  near  the  sternal  notch.  Vocal  resonance 
is  diminished  or  absent  within  the  area  of  dullness  or  flatness, 
and  also  vocal  fremitus.  In  most  cases  the  fluid  disappears  rap- 
idly within  a  week  or  ten  days. 

The  tli  ii'd  stage  is  the  stage  of  absorption.  As  the  effu- 
sion is  absorbed,  the  friction  murmur  and  fremitus  reappear  and 
the  area  of  dullness  lessens  (  Bartholow,  Flint  and   Loomis). ' 

Differential  Diagnosis. — Pericarditis  may  be  confounded  with 
endocarditis,  hydropericardiuni,  cardiac  hypertrophy  and  left 
pleurisy.  In  pericarditis,  the  friction  murmur  is  a  sound  of 
rasping  or  crackling  and  superficial  in  character,  varying  froni 
one  hour  to  another  in  intensity  and  increases  with  pressure  of 
the  stethoscope  on  the  chest  wall.  It  also  increases  in  loudness 
with  the  upright  position  and  bending  forward.  The  friction 
murmur  disappears  when  the  effusion  reaches  a  certain  amount. 
There  is  an  increase  of  percussion  dullness. 

In  endocarditis,  the  endocardial  murmur  is  a  soft,  smooth, 
blowing  sound,  deep  in  character,  remaining  constant,  is  not 
affected  by  pressure  of  stethoscope  on  chest  wall,   and  is  most 


PERICARDITIS.  391 

distinct  in  the  recumbent  position.  The  endocardial  murmur  is 
permanent.  There  is  no  increase  of  percussion  dullness.  In 
plewisy,  the  friction  sound  is  synchronous  with  the  respiration; 
in  pericarditis  it  is  synchronous  with  the  cardiac  movements; 
suspension  of  respiration  arrests  the  former,  but  does  not  affect 
the  latter.  In  pleurisy  with  effusion,  all  voice  and  breath  sounds 
disappear;  in  pericarditis,  they  are  unaffected.  Ht/dropericard- 
ium  is  to  be  distinguished  from  pericarditis  by  the  absence  of 
fever,  local  pain  and  friction  murmur. 

In  hypertroplty  of  the  heart,  the  action  is  heaving,  there  is 
an  increase  in  the  force  of  the  apex- beat,  and  an  abnormal  in- 
tensity to  the  heart  sounds;  in  pericarditis  all  these  will  be 
diminished  in  intensity.  In  hypertrophy  of  the  right  heart  the 
precordial  dullness  never  extends  to  the  left  beyond  the  apex 
beat,  while  in  pericardial  effusion  it  may  extend  one  or  two 
inches  beyond  the  apex-beat.  In  hypertrophy  or  dilatation  of 
the  left  heart,  the  apex -beat  is  carried  downward  and  to  the  left, 
and  the  area  of  dullness  is  increased  in  the  same  direction  and 
not  to  the  right,  as  in  pericarditis  (Bartholow  and  Loomis). 

Prognosis. — Simple  and  rheumatic  pericarditis  are  not  often 
fatal.  As  an  intercurrent  disease,  coming  on  in  the  course  of 
scorbutis,  pyaemia,  puerperal  diseases,  Bright's  disease,  some  of 
the  eruptive  fevers,  pneumonia,  etc.,  it  is  extremely  fatal.  A 
large  amount  of  fluid  may  compress  and  cause  paralysis  of  the 
heart.  In  rare  instances  a  fatal  syncope  occurs  (Bartholow  and 
Loomis). 

Treatment. — Discover  and  remove  the  cause  if  possible. 
Absolute  rest  in  bed  must  be  enjoined.  Opium  is  the  most 
valuable  internal  agent  for  the  pain  and  constitutional  disturb- 
ance. As  pericarditis  is  a  disease  of  the  weak  and  feeble,  and 
the  young,  iron,  stimulants,  and  a  highly  nutritious  and  readily 
digestible  diet  are  the  most  efficient  remedies  (Loomis).  In  the 
first  stage  Bartholow  recommends  a  full  dose  of  quinine  (gr.  xx.) 
with  half  a  grain  of  morphine.  He  would  also  give  five  grains 
of  the  carbonate  of  ammonia  every  two  hours,  when  the  exuda- 
tion is  forming.  The  same  authority  would  give  infusion  of 
digitalis  in  a  tablespoonful  dose  every  four  hours.  To  promote 
absorption,  the  prsecordia  may  be  painted  with   the   tincture  of 


392  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

iodine  daily.     The  operation  of  paracentesis  is   required  when 
the  effusion  is  great,  or  when  it  is  purulent  (Bartholow). 

PRESCRIPTIONS  FOR  PERICARDITIS. 

J$-     Antimonii  et  potassii  tart gr .  iv. 

Tinct.  opii 3J . 

Aqua?  camphorse 3viij. — M. 

Sig. :     A  tablespoonful  every  two  hours.  — Graves. 

{fcr     Hydrargyri  chloridi  mitis 

Pulv.  ipecac aa gr.  vj. 

Potassii  nitratis oss.-j. — M. 

In  pulv.  no.  xii.  div. 
Sig. :     A  powder  every  three  hours.  — Hartshorne. 

JJr     Tinct.  aconiti  radicis 3ss. 

Sig. :     Half  a  drop  to  a  drop  every  quarter  of  an  hour  for  two 
hours,  then  every  hour  or  two.  — Ringer. 

{Jr     Empl  cantharidis 2x3  inches. 

Sig.:     Apply  over  the  precordial  space.  Repeat  at  intervals  after 
the  skin  is  healed.     (In  chronic  stage.)  — Tanner. 

PERIOSTITIS. 

Is  an  inflammation  of  the  periosteum.  Endostitis  is  an 
inflammation  of  the  endosteum.  Ostitis  is  an  inflammation  of 
bone.     Inflammation  of  these  structures  may  be  acute  or  chronic. 

Causes. — Acute  inflammation  of  bone  whether  originating 
in  the  periosteum  or  endosteum  is  chiefly  found  during  the 
growing  period  of  bone,  and  is  a  very  grave  affection.  It  occurs 
in  the  feeble  and  cachectic,  and  in  those  termed  scrofulous.  It 
occurs  in  the  shafts  of  the  long  bones  as  well  as  in  the  epiphysis, 
and  in  those  most  exposed,  as  the  tibia  and  ulna.  It  is  also  seen 
in  the  femur.  It  is  often  the  result  of  some  local  injury  or  ex- 
posure.    In  some  cases  there  is  no  assignable  cause  (Bryant). 

Termination. — It  may  end  in  local  abscess  of  bone,  in  diffused 
suppuration,  or  in  the  more  or  less  complete  death  of  the  bone. 
The  bone  by  the  inflammation  has  been  deprived  of  its  vascular 
supply  through  a  blocking  of  its  capillaries,  its  death  resulting 
from  blood  stasis  (Bryant). 


PERIOSTITIS.  393 

Symptoms. — The  disease  is  usually  ushered  iu  with  a  deep 
achiug  pain  iu  the  bone,  with  local  tenderness,  often  a  rigor, 
followed  by  intense  constitutional  disturbance  and  increase  of 
temperature,  and  by  swelling  and  immobility  of  the  limb.  If 
the  origin  of  the  disease  is  in  the  periosteum,  the  skin  soon  be- 
comes red;  if  in  the  endosteum,  many  days  will  pass  before  red- 
ness appears.  When  pus  forms,  the  skin  becomes  inflamed, 
rigors  become  more  frequent,  pain  is  more  intense,  sleeplessness 
and  delirium  appear,  and  unless  relief  be  afforded  by  a  free  in- 
cision down  to  the  bone,  death  by  exhaustion,  and  probably  by 
blood-poisoning  is  apt  to  occur  (Bryant). 

Treatment. — In  all  cases  of  acute  inflammation  of  bone  or  peri- 
osteum, there  is  no  treatment  equal  to  that  of  a  free  incision 
down  to  the  bone.  It  is  not  necessary  to  wait  for  the  formation 
of  pus  before  making  the  incision.  The  object  of  the  incision  is 
to  relieve  tension  and  thereby  relieve  pain.  The  limbs  should  be 
elevated  and  hot  fomentations  applied.  Pain  should  be  relieved 
by  morphine  (Bryant). 

CHRONIC  PERIOSTITIS  AND  OSTITIS. 

Are  very  common  affections  more  particularly  involving  the 
shafts  of  the  long  bones. 

Causes. — These  affections  may  be  modified  by  syphilis,  scrof- 
ula or  rheumatism,  and  may  originate  from  some  local  cause  or 
injury  (Bryant). 

Symptoms. — Are  similar  to,  though  less  severe  than  those  of 
the  acute,  the  most  constant  being  a  dull,  achingpain  in  the  part 
of  a  persistent  kind,  aggravated  at  intervals  and  on  hanging 
down  the  limb,  the  pain  being  almost  always  worse  at  night, 
more  particularly  in  syphilitic  affections  (Bryant). 

Differential  Diagnosis. — In  periostitis  the  pain  is  local,  with 
swelling  early;  tenderness  on  manipulation  is  an  early  and  con- 
stant symptom;  there  is  enlargement  of  bone  with  one  or  two  or 
more  nodes  upon  its  surface,  and  when  suppuration  is  about  to 
take  place,  increased  swelling,  tenderness  and  redness  will  be 
present. 

///  endostitis  the  pain  is  diffused  through  the  whole  bone, 
and  will  continue  for  weeks  and   months  without  swelling;    the 


394  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

bone   may  be   manipulated  without  pain,   and   enlargement   of 
bone  in  all  directions  takes  place  (Bryant). 

Treatment. — When  suppuration  does  not  take  place,  fomen- 
tations, with  the  elevation  of  the  limb,  sedatives  to  allay  pain, 
and  the  internal  use  of  the  iodide  or  bromide  of  potassium  are 
the  most  efficient  means.  A  blister  or  tincture  of  iodine  may  be 
useful.  When  pain  is  severe  opium  internally  and  belladonna 
externally  give  relief.  When  pus  has  formed  make  an  incision 
(Bryant). 

PERITONITIS. 

Is  an  inflammation  of  the  whole  or  a  part  of  the  serous  mem- 
brane which  lines  the  abdominal  wall  and  covers  the  viscera 
contained  in  the  abdominal  cavity.  It  maybe  acute  or  chronic; 
local  (circumscribed)  or  general  (diffuse) ',  primary  or  secondary 
(Looniis). 

Causes. — Peritonitis  may  occur  at  any  age  in  the  strong  and 
robust  as  well  as  in  the  weak  and  feeble.  As  a  primary  disease 
it  is  rare.  The  exciting  causes  are:  1.  Intestinal  obstructions 
and  perforations.  Under  this  head  may  be  included  typhlitis 
and  perityphlitis  with  ulceration;  rupture  of  hepatic  and  other 
abscesses ;  ulceration  and  rupture  of  the  stomach,  gall  and  urinary 
bladder;  rupture  of  hydatid  and  ovarian  cysts;  ulcerations  and 
perforations  of  the  intestines  in  typhoid  fever,  and  syphilitic  or 
tubercular  intestinal  ulcers.  Injections  into  the  uterus,  rupture 
of  an  organ  from  a  blow  or  fall,  penetrating  wounds  of  the  ab- 
domen and  necrosis  of  the  spine,  ribs  or  pelvic  bones,  are  causes. 

2.  Extension  of  inflammation  as  from  the  stomach  or 
intestines,  from  the  uterus  and  its  appendages,  liver,  spleen  and 
kidneys,  from  typhlitis,  perityphlitis,  proctitis  and  periprocti- 
tis, ulcer  of  the  rectum,  intussusception,  volvulus  and  hernia  of 
the  intestine. 

3.  Peritonitis  is  frequently  an  intercurrent  malady  coming 
on  in  the  course  of  a  certain  cachexige,  as  pyaemia,  septicaemia, 
puerperal  fever,  albuminuria,  the  eruptive  fevers,  erysipelas, 
long  standing  ascites,  general  tuberculosis  and  cancer,  etc.  Tu- 
bercular peritonitis  is  met  with  most  frequently  in  early  life,  and 


PEKITONTTIS.  395 

cancerous  peritonitis  between  the  ages  of  40  and  60.  Exposure 
to  cold  and  wet  may  cause  it  (Bartholow  and  Loomis). 

Symptoms. — If  peritonitis  is  the  result  of  intestinal  perfora- 
tion, its  onset  will  be  marked  by  excessive  pain  over  the  whole 
abdomen.  In  infectious  peritonitis,  the  first  symptom  will  be  a 
severe  chill.  Peritonitis  resulting  from  an  extension  of  inflam- 
mation, begins  with  local  and  gradually  increasing  pain.  All 
varieties  of  acute  peritonitis  are  ushered  in  by  pain  as  one  of  the 
earliest  symptoms.  The  pain  may  be  local  or  diffuse,  and  is  de- 
scribed as  a  cutting,  burning  j3ain,  aggravated  by  pressure  and 
movements  of  the  abdomen.  The  pain  causes  the  patient  to 
remain  motionless  on  his  back,  with  the  knees  drawn  up,  the  res- 
pirations are  rapid  and  superficial,  and  the  face,  by  its  pallid, 
drawn  and  anxious  look  is  almost  diagnostic  of  the  disease.  In 
general  peritonitis  the  abdomen  soon  becomes  distended  and 
tympanitic.  At  first  the  abdominal  muscles  are  rigid  and  con- 
tracted, but  soon  relax.  The  temperature,  in  most  cases,  ranges 
from  102°  to  103°  F.  In  fatal  cases  it  may  fall  below  the  normal 
during  the  period  of  collapse. 

The  pulse  is  accelerated,  often  reaching  140  per  minute.  It 
is  small,  hard  and  wiry  in  character.  For  hours  before  a  fatal 
issue  it  may  beat  200  per  minute.  Vomiting  is  a  prominent 
symptom,  and  at  first  articles  of  food  and  gastric  mucus  come  up 
then  biliary  matters  from  the  duodenum.  Whenever  stercorace- 
ous  vomiting  occurs  in  peritonitis,  it  is  evidence  of  intestinal  ob- 
struction. 

The  tongue  is  coated  and  the  appetite  impaired  at  the  onset. 
Constipation  is  the  rule  in  peritonitis.  It  is  due  to  paresis  of  the 
bowel.  The  urine  is  scanty,  and  then  there  may  be  retention  or 
strangury,  if  the  inflammation  extends  to  the  bladder.  In  acute 
peritonitis  there  is  a  tendency  to  heart  failure  and  collapse.  In 
all  varieties  disease  rarely  runs  a  typical  course;  even  pain 
may  be  absent.  When  peritoDitis  follows  intestinal  perforation, 
all  the  symptoms  from  the  onset  are  severe.  The  face  quickl)^ 
becomes  haggard,  drawn  and  dejected;  the  eyes  are  sunken  and 
surrounded  by  dark  purple  rings;  the  nose  and  cheeks  are 
pinched,  the  lips  are  blue,  the  voice  feeble,  the  extremities  cold 
and  covered  with  sweat,  the  pulse  very  weak,  "  Cheyne- Stokes" 


396  a  compendium:  of  pkactical    medicine. 

respiration  and  death  is  within  48  hours.  The  mind  is  usually 
clear  throughout  the  entire  course  of  the  disease:  but  in  infect- 
ious peritonitis  loss  of  consciousness,  apathy,  or  delirium  may 
precede  death  by  a  few  hours.  In  cases  of  much  effusion  the 
pain  subsides.  In  suppurative  peritonitis  the  pain  is  frequently 
absent,  but  typhoid  symptoms  are  present  from  the  onset,  delir- 
ium and  rigors  are  common,  and  the  pulse  becomes  very  rapid. 
Occasionally,  when  perforation  of  the  bowel  or  stomach  takes 
place,  the  patient  has  the  feeling  as  if  somethiug  had  suddenly 
burst  or  been  torn  within  the  abdomen. 

Local  or  Circumscribed  Peritonitis. — Usually  pursues  a 
sub- acute  rather  than  an  acute  course.  Chronic  peritonitis 
(non- tubercular  and  non- cancerous)  is  usually  the  sequel  of  an 
acute  attack.  If  an  acute  attack  does  not  subside  in  one  week, 
it  becomes  chronic  and  there  is  a  gradual  increase  in  the  size  of 
the  abdomen,  with  rigors  and  sweats.  There  is  rapid  loss  of 
flesh  and  strength.  The  face  is  haggard  and  drawn.  The  pain 
assumes  a  colicky  character  and  is  a  "dull  ache."  The  pulse  is 
small  and  rapid.  There  is  anorexia  with  vomiting.  The  tem- 
perature is  99°  to  104°  F. 

Tubercular  Peritonitis. — In  tubercular  peritonitis  the  pain 
is  paroxysmal  in  character.  It  often  occurs  suddenly  with  rapid 
and  feeble  pulse,  fever,  nausea,  vomiting  and  diarrhoea.  The 
tongue  is  coated.  The  skin  is  harsh  and  dry.  There  is  great 
thirst  and  rapid  loss  of  flesh  and  strength.  Typhoid  symptoms 
come  on  early.  Effusion  into  the  peritoneal  cavity  takes  place 
and  the  patient  dies  of  asthenia.  Kedness  and  oedema  about  the 
umbilicus  are  regarded  as  characteristic  of  tubercular  peritonitis. 
Hectic  fever  is  accompanied  by  profuse  sweats  during  sleep,  and 
the  abdomen  has  a  doughy  feel.  The  pain  may  be  so  slight  as 
to  amount  only  to  a  sense  of  tension  and  fullness  in  the  abdo- 
men. Some  cases  are  unattended  by  ascities,  and  knots  of  intes- 
tine embedded  in  firm  hard  masses  are  felt  in  the  region  of  the 
umbilicus.  Friction  sounds  may  be  heard  over  these  masses. 
Tubercular  peritonitis  may  have  for  its  chief  and  only  symptoms 
ascites,  anaemia,  and  the  evidences  of  general  tuberculosis.  Occa- 
sionally its  progress  is  interrupted,  and  there  is  marked  improve- 
ment and  cessation  of  all  the  abdominal  symptoms,  and  then 


PERITONITIS.  397 

there  follows  a  period  when  death  seems  iirmiinent.  The  mesen- 
teric glands  are  usually  enlarged. 

Cancerous  Peritonitis. — Is  attended  by  the  same  local 
symptoms  as  tubercular.  Sometimes  a  tumor  may  be  felt,  espe- 
cially in  the  region  of  the  omentum  and  mesentary.  There  is 
always  ascites;  the  fluid  collects  gradually,  and  often  in  very 
large  quantities.  In  some  cases  the  abdomen  is  very  sensitive, 
and  paroxysms  of  colicky  pains  are  frequent.  The  temperature 
rarely  reaches  100°  F.  The  diagnosis  rests  on  the  presence  of  a 
gradually  increasing  tumor  and  the  cancerous  cachexia  (Bar- 
tholow  and  Loomis). 

Differential  Diagnosis. — Peritonitis  may  be  confounded  with 
intestinal  colic,  intestinal  obstruction,  enteritis,  abdominal  neu- 
ralgia, hysteria,  rheumatism  of  the  abdominal  muscles,  renal  and 
biliary  colics,  and  suppurative  cellulitis  of  the  abdominal  walls. 
The  ascites  of  chronic  peritonitis  may  be  mistaken  for  that  of 
the  last  stages  of  cirrhosis  of  the  liver.  Gastric  symptoms  are 
prominent  in  cirrhosis  and  absent  in  peritonitis.  The  counte- 
nance has  a  clay- colored  or  jaundiced  hue  in  cirrhosis;  in  peri- 
tonitis it  is  pale  and  anxious.  The  liver  is  diminished  and  the 
spleen  increased  in  size  in  cirrhosis.  The  abdomen  is  excess- 
ively tender  in  chronic  peritonitis,  and  the  fluid  accumulates 
more  rapidly  than  in  cirrhosis.  In  peritonitis  there  is  usually  a 
distinct  febrile  movement,  the  pulse  is  accelerated  and  is  tense 
and  wiry  in  character.  In  colic  there  is  no  fever  or  increase  in 
pulse-rate,  the  rule  being  rather  a  slowed  pulse.  In  peritonitis 
the  patient  avoids  the  slightest  motion  of  the  body,  and  firm 
pressure  over  the  abdomen  increases  the  pain,  while  in  colic  the 
patient  tosses  from  one  side  to  the  other,  and  firm  pressure  over 
the  abdomen  relieves  the  pain.  The  pain  of  peritonitis  is  con- 
stant, that  of  colic  paroxysmal. 

Intestinal  obstruction,  if  it  begins  with  colicky  pains,  is 
soon  attended  by  faecal  vomiting,  the  pain  is  localized,  there  is  a 
subnormal  temperature  and  more  distention  of  the  abdomen; 
while  peritonitis  is  attended  by  fever,  by  great  tenderness  on 
pressure,  by  a  tense,  hard,  wiry  pulse,  and  by  rigidity  of  the 
abdominal  walls.  Peritonitis  comes  on  rapidly,  and  at  its  onset 
the   abdomen  becomes   exceedingly  tympanatic    and   tender   to 


398  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

pressure,  while  enteritis  comes  on  slowly  and  excessive  tympanites 
is  rare.  In  enteritis  the  vomiting  is  severe;  in  peritonitis  rare. 
There  is  constipation  in  peritonitis,  while  diarrhoea  is  the  rule  in 
enteritis.  The  pulse  is  tense  and  wiry  in  peritonitis,  rapid  and 
feeble  in  enteritis.  The  fever  is  higher  in  enteritis.  The  symp- 
toms of  collapse,  the  anxious  face,  superficial  respiration,  and 
immobility  of  the  patient  are  characteristic  of  peritonitis. 

In  abdominal  neuralgia,  the  pain  simulates  that  produced 
by  a  tightly  drawn  cord  about  the  abdomen,  and  follows  the 
course  of  the  genito- crural  nerve.  There  is  tenderness  on  pres- 
sure only  at  the  point  of  exit  of  the  nerve  from  the  spine.  The 
tympanites,  the  ascites,  the  fever,  the  rapid  pulse,  the  signs  of 
collapse,  and  the  muscular  rigidity  of  peritonitis  are  all  absent 
in  neuralgia.  In  hysteria  the  firmest  pressure  does  not  increase 
the  pain  if  the  attention  of  the  patient  is  engaged. 

The  rapid  pulse,  fever,  signs  of  collapse,  and  anxious  face  of 
peritonitis  are  absent,  and  there  is  present  the  globus  hystericus, 
and  the  attack  is  followed  by  the  passage  of  a  large  quantity  of 
watery,  straw-colored  urine.  In  rheumatism  of  the  abdominal 
muscles,  the  pain  and  tenderness  are  most  intense  at  the  origin 
and  insertion  of  the  muscles.  There  is  no  fever,  no  vomiting, 
and  no  signs  of  collapse.  The  pulse  is  normal.  There  is  a  his- 
tory of  rheumatism.  In  biliary  colic  the  patient  throws  himself 
about  in  excruciating  agony,  and  the  pain  is  referred  to  the  re- 
gion of  the  common  bile-duct,  is  paroxysmal  in  character,  and 
will  shoot  back  from  the  margin  of  the  ribs  over  the  gall-blad- 
der to  the  spinal  column.  If  it  continues  24  hours  the  patient 
becomes  jaundiced.  In  renal  colic,  the  pain  radiates  from  the 
kidney  along  the  ureter  to  the  testicle  which  is  retracted.  In 
both  these  colics  there  is  no  fever,  no  rapid  pulse  and  no  tymp- 
anites or  tenderness  on  firm  pressure.  In  suppurative  cellulitis, 
of  the  abdominal  walls,  the  superficial  swelling  and  the  absence 
of  constitutional  symptoms  of  peritonitis  establish  the  diagnosis 
(Bartholow,  Flint  and  Loomis). 

Prognosis. — Acute  general  peritonitis  is  always  a  grave  dis- 
ease. Its  average  duration  is  from  four  to  eight  days.  The 
usual  termination  is  in  death.  When  it  arises  from  perforation, 
a  fatal  result  may  occur  in  two  or  three  days.    The  gravest  cases 


PERITONITIS.  399 

are  those  which  occur  in  the  course  of  septic  diseases.  General 
puerperal  peritonitis  is  almost  always  fatal.  Peritonitis  from 
rupture  of  an  organ  is  always  fatal.  The  prognosis  is  favorable 
when  the  peritonitis  is  due  to  extension  of  innammation  from  a 
viscus.  Tubercular  peritonitis,  after  weeks  and  months  of  anae- 
mia and  exhaustion,  terminates  in  death.  The  same  may  be  said 
of  carcinomatous  peritonitis  (Bartholow  and  Loomis). 

Treatment. — In  the  strong  and  robust  at  the  very  onset  of 
the  attack,  ten  to  twenty  leeches  may  be  applied  over  the  abdo- 
men. While  acute  peritonitis  is  progressing  the  bowels  cannot 
he  moved,  and  no  benefit  would  result  if  they  were,  so  that  under 
no  circumstances  should  there  be  an  attempt  at  purgation.  The 
opium  plan  of  treatment  first  developed  and  brought  to  the 
notice  of  the  profession  by  Prof.  Alonzo  Clark,  is  the  most  effi- 
cacious. With  the  first  symptoms  of  peritonitis,  give  at  one  dose 
from  two  to  five  grains  of  opium,  or  one-half  to  one  grain  of 
morphine  every  two,  four,  six  or  eight  hours  according  to  the 
effect.  The  rule  is  to  bring  the  jDatient  as  soon  as  jzjossible  fully 
under  the  influence  of  the  drug,  and  maintain  a  moderate  degree 
of  narcotism,  not  until  all  pain  and  tenderness  have  subsided, 
but  until  the  pulse  has  reached  its  normal  standard  and  tympan- 
ites has  entirely  subsided.  When  the  patient  is  fully  under  the 
influence  of  the  opiate,  the  entire  surface  of  the  body  becomes 
bathed  in  a  profuse  perspiration.  In  24  hours  a  rash,  due  to  the 
opium,  will  make  its  appearance  with  an  itching  of  the  surface 
and  nose.  The  pupils  become  contracted,  the  eyes  suffused,  the 
countenance  assumes  a  dull  expression,  there  is  a  constant  desire 
to  sleep,  the  pulse  becomes  less  rapid,  and  the  respirations  may 
be  only  twelve  in  a  minute.  Now  the  patient  is  in  the  condition 
in  which  it  is  desirable  to  keep  him,  and  with  the  respirations 
at  twelve  per  minute  he  is  perfectly  safe.  If  it  is  found 
difficult  to  arouse  the  patient,  the  administration  of  opium 
must  be  stopped  until  he  can  be  easily  aroused.  When 
the  pulse  becomes  less  frequent  and  the  tympanites  subsides, 
one  may  be  certain  that  he  is  controlling  the  peritonitis. 
By  this  plan  of  treatment  an  acute  peritonitis  may  be  con- 
trolled within  48  hours  from  its  onset;  but  the  treatment 
must  be  continued  four  or  five  days  longer  for   fear   of  relapse. 


400  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Wait  at  least  a  week  before  giving  a  cathartic  (castor-oil).  The 
local  applications  should  consist  of  warm  fomentations,  mustard 
plasters,  or  tincture  of  iodine.  At  the  beginning  large  doses  of 
quinine  are  in  a  high  degree  beneficial.  The  vital  powers  must 
be  kept  up  by  suitable  nutrients  and  stimulants.  Ice  may  be 
given  to  relieve  the  thirst.  If  hiccough  is  distressing,  it  should 
be  relieved  temporarily  by  the  inhalation  of  chloroform.  Vomit- 
ing is  sometimes  allayed  by  carbonated  water,  ice  and  champagne, 
or  hydrocyanic  acid.  Turpentine,  as  an  injection  and  employed 
locally  will  sometimes  relieve  the  tympanites.  Bartholow  be- 
lieves that  ten  grains  of  the  carbonate  of  ammonium  in  an  ounce 
of  the  solution  of  the  acetate,  every  four  hours,  when  the  exuda- 
tion is  going  on,  is  a  remedy  of  the  highest  utility.  In  the 
peritonitis  from  perforation  absolute  repose,  opium,  ice,  and  the 
avoidance  of  all  foods  and  drinks,  are  the  proper  measures.  In 
puerperal-peritonitis,  great  attention  should  be  paid  to  the  uterus. 
In  chronic  peritonitis,  iodide  of  potassium  should  be  given  in- 
ternally, and  iodine  and  mercury  should  be  applied  locally.  The 
effusion  may  be  removed  by  tapping.  In  tubercular  peritonitis, 
small  doses  of  opium,  with  tonics  and  cod- liver  oil,  may  be 
given,  and  warm  anodyne  applications  to  the  abdomen.  In  can- 
cerous peritonitis,  the  treatment  is  symptomatic  (Bartholow, 
Flint  and  Loomis). 

PERTUSSIS. 

Called  also  whooping-cough,  is  an  acute  contagious  disease, 
occurring  chiefly  in  childhood,  and  once  only  during  life;  it  is 
characterized  by  successive  forcible  expirations,  and  at  their 
termination  by  a  loud,  resounding,  sonorous  inspiration  (Bar- 
tholow). 

Causes. — A  large  majority  of  the  cases  occur  between  the 
ages  of  one  and  ten  years.  The  special  exciting  cause  of  this 
disease  is  a  contagious  principle  which  acts  upon  the  respiratory 
organs.  The  specific  poison  is  given  off  in  the  breath  of  the  af- 
fected and  conveyed  through  the  air,  or  in  clothes  to  the  healthy. 
It  affects  all  races  and  classes  and  is  more  prevalent  in  winter 
and  spring.     It  may  occur  as  an  epidemic.     The  period  of  incu- 


PEKTTJSSIS.  401 

bation  varies  from  five  days  to  two  weeks  (Smith  and  Bartho- 
low). 

Symptoms. — There  are  three  stages  of  this  disease;  first,  that 
of  catarrh  of  the  air-passages;  second,  the  stage  of  spasmodic 
cough;  third,  the  stage  of  decline.  The  first  stage  is  character- 
ized by  the  symptoms  of  coryza  and  bronchitis.  The  eyes  may 
be  suffused,  there  is  sneezing,  cough  begins,  and  there  may  be 
fever,  thirst  and  impaired  appetite.  The  duration  of  the  first 
stage  varies  from  eight  to  fifteen  days.  The  spasmodic  stage  is 
characterized  by  the  spasmodic  cough.  The  cough  consists  of  a 
succession  of  short,  rapid  expiratory  efforts;  the  face  gets  red; 
the  eyes  swell  and  protrude  and  the  body  is  bent  forward  in 
coughing,  then  when  the  breath  is  entirely  exhausted,  a  deep, 
loud,  crowing  inspiration  occurs.  During  each  paroxysm  there 
may  be  two,  three  or  more  of  such  efforts,  and  at  the  expiration 
of  them  the  patient  brings  up  a  quantity  of  tenacious,  glary  mu- 
cus, and  is  often  accompanied  by  vomiting.  The  duration  of  the 
paroxysms  varies  from  a  few  seconds  to  several  minutes,  and  the 
number  of  them  daily,  varies  from  ten  to  a  hundred.  They  are 
most  frequent  at  night.  The  duration  of  the  second  stage  is  from 
30  to  60  days.  The  third  stage  or  stage  of  decline  is  short,  not  con- 
tinuing longer  than  two  or  three  weeks  (Smith  and  Bartholow). 

Complications. — The  cerebral  complications  consist  in  con- 
vulsions, hydrocephalus,  and  cerebral  congestion.  The  lung 
complications  are  pulmonary  congestion,  bronchitis,  pneumonia 
and  emphysema.  Capillary  bronchitis  and  pneumonia  are  always 
serious  complications  (Smith,  J.  L.). 

Prognosis. — Whooping-cough  is  always  a  serious  disease, 
although  it  is  rarely  directly  fatal;  yet  indirectly  it  frequently 
causes  death  (Loomis). 

Treatment. — Is    symptomatic.     Alum    is   recommended  by 

Golding  Bird  (gr.  iv.  every  four  hours),  and  Meigs  says  it  is  the 

best  remedy.     In  the  catarrhal  stage   the  following  formula  of 

Bartholow  may  be  used  : 

|fc     Syrupi  scillre  comp 5j. 

Tinct.  aconiti  rad lllxvj. 

Tinct.  opii  deodorat ITTviij. 

Syrupi  tolu gvij. 

A  quae  lauro-cearsi  5J . — M. 

Sig. :     A  teaspoonful  every  two,  three  or  Jour  hours. 


402  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Tincture  of  aconite,  tincture  of  belladonna,  deodorized  tinc- 
ture of  opium  and  fluid  extract  of  ipecac  in  suitable  proportions 
according  to  age,  is  a  most  serviceable  combination.  If  the 
child  is  old  enough  a  gargle  of  bromide  of  potassium  may  be 
used  with  advantage. 

Bartholow  would  give,  in  the  spasmodic  stage,  opium,  in  the 
form  of  codeine,  which  can  be  employed  with  proper  precautions, 
eyen  in  the  case  of  infants.  A  slight  hypnotic  effect  should  be 
maintained  constantly.  The  mono -bromide  of  camphor  in  from 
two  to  ten  grains  every  four  hours  seems  to  be  most  beneficial. 
The  very  best  results,  and  often  an  immediate  arrest  of  the  dis- 
ease, can  be  procured  by  full  doses  of  quinine.  Dilute  hydro- 
cyanic acid  and  nitric  acid  well  diluted  are  useful  remedies. 
Good  results  are  obtained  by  inhalation  of  carbolic  spray  in 
many  cases.  A  one  per  cent,  solution  is  strong  enough  for  this 
purpose.  Sonnenberger  regards  antipyrine  as  a  specific  in  doses 
of  one  and  a  half  grains  three  times  daily  for  a  child  one  year  old. 
Peroxide  of  hydrogen  has  been  used  as  a  spray  to  the  fauces  with 
some  success.  Whooping-cough  is  a  self -limited  disease  and 
must  be  treated  expectantly.  The  patient,  by  warm  clothing, 
should  guard  against  undue  exposure  (Smith,  Bartholow  and 
Loomis). 

PHAGEDENA, 

Is  molecular  gangrene,  or  rapid  ulceration.  This  variety  of 
ulcer  spreads  with  great  rapidity,  destroying  everything  within 
its  reach. 

Causes. — Are  general  and  local.  Bad  hygiene,  misery,  diges- 
tive troubles,  scrofula,  scorbutus,  malaria,  chronic  alcoholism  and 
old  age  are  prominent  general  causes.  It  is  frequently  met  with 
in  persons  broken  down  with  disease,  or  who  are  much  debili- 
tated. The  local  causes  are:  lack  of  cleanliness,  phimosis  from 
retention  of  pus,  and  all  sorts  of  local  irritation.  Phagedena, 
most  commonly  found  with  chancroid,  is  not  confined  to  this 
variety  of  sore.  Syphilitic  chancre  is  sometimes  phagedenic; 
different  ulcerated  syphilides  and  scrofulides  occasionally  become 
phagedenic. 


PHAGEDENA.  403 

Phagedena  attacks  virulent  bubo  perhaps  as  often  as  it  does 
chancroid.  Phagedena  is  not  a  property  belonging  to  chancroid 
pus,  it  is  rather  a  property  of  the  tissues  of  the  patient.  Hence 
the  conclusion  is,  that  there  is  no  special  phagedenic  virus.  No 
definite  duration  can  be  assigned  to  phagedena.  The  bottom  of 
a  phagedenic  ulcer  is  liable  to  be  covered  with  a  slough  which  is 
of  a  grayish  color.  The  discharge  is  serious,  profuse,  and  highly 
offensive  (Keyes).  Phagedenic  sores  are  rarely  seen  except  in 
connection  with  syphilis  or  hospital  gangrene.  In  syphilis 
sloughing  is  found  in  the  intemperate  and  ill-fed,  and  mostly  in 
gin -drinking  prostitutes  (Bryant). 

Treatment. — Cleanse  the  part  by  soaking  up  with  absorbent 
cotton  all  the  discharges  from  the  ulcer  that  may  be  present; 
then  destroy  the  edges  of  the  ulcer  with  some  one  of  the  acids. 
When  this  has  been  done,  touch  the  edges  of  the  sore  with  ab- 
sorbent cotton  saturated  with  nitrate  of  mercury  one  part,  water 
eight  parts,  and  insert  the  cotton  under  the  undermined  edges  of 
the  sore.  Having  done  this,  sprinkle  the  edges  with  iodoform. 
Surrounding  the  slough  is  an  acutely  inflamed  surface;  paint  this 
with  the  tincture  of  iodine  and  dress  the  limb  with  a  solution  of 
acetate  of  lead  and  laudanum,  keeping  the  parts  in  an  elevated 
and  relaxed  position.  Give  the  patient  nourishing  diet,  quiniue 
and  iron,  and  stimulants  if  necessary,  If  the  pain  is  severe  give 
one  grain  of  opium  every  eight  hours  (Horwitz). 

PHARYNGITIS. 

Is  an  inflammation  of  the  mucous  membrane  of  the  tonsils 
uvula,  soft  joalate,  and  pharynx.  It  may  be  acute  or  chronic 
(Loomis). 

Causes. — The  most  j^rolific  cause  is  taking  cold.  Next  to 
this  is  the  use  of  cigarettes,  and  then  comes  alcoholic  excess. 
Diphtheria,  the  eruptive  fevers,  and  inflammatory  affections  of 
the  air  passages  are  accompanied  by  this  disease.  Acute  pharyn- 
gitis is  one  of  the  forms  of  "ordinary  sore  throat."  It  occurs 
most  frequently  in  children  and  in  young  adults.  One  attack 
predisposes  to  others.  Chronic  follicular  pharyngitis  may  be 
produced  by  prolonged  use  of  the  voice  in  public  sj3eakW  or 


404  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

singing.  Weak,  scrofulous  persons  are  affected  with  it.  It  is 
sometimes  called  clergyman 's  sore  throat  (Bartholow  and 
Loomis). 

Symptoms. — In  acute  cases,  there  is  at  first  an  unpleasant, 
stuffy  and  dry  feeling  in  the  naso-pharyngeal  space,  followed 
later  by  secretion.  There  may  be  severe  headache  and  pains  in 
the  upper  jaw.  Breathing  through  the  nose  is  difficult.  The 
voice  is  thick  and  nasal.  An  acute  attack  subsides  in  a  few 
days.  In  the  chronic  form,  the  posterior  nares  are  more  or  less 
obstructed  by  the  swelling  of  the  mucous  membrane.  Pain  in 
the  ear  may  be  felt,  and  dullness  of  hearing  is  a  common  symp- 
tom from  obstruction  of  the  Eustachian  tube.  The  mucus  in  the 
pharynx  excites  frequent  attenrpts  to  swallow,  and  patients  often 
"clear  the  throat"  before  speaking  (Bartholow). 

Treatment. — In  acute  pharyngitis,  ice  cold  carbonated  water 
affords  the  greatest  relief  during  the  first  twenty-four  hours.  The 
throat  and  mouth  should  be  frequently  sjDrayed  with  a  solution 
of  alum,  tannin  or  sulphate  of  zinc,  and  at  the  same  time  the  wet 
pack  should  be  applied  to  the  throat  either  hot  or  cold.  The 
naso-pharyngeal  cavity  may  be  washed  out  with  a  solution  of 
common  salt  or  carbonate  of  sodium.  Of  the  gaseous  remedies 
none  is  so  curative  as  ethyl -iodide  which  can  be  inhaled  without 
apparatus.  It  can  be  vaporized  at  100°  F.,  and  the  sinrplest  in- 
haler used.  The  vapor  may  be  inhaled  once  daily  through  the 
nose  for  sometime.  As  a  topical  remedy  a  mixture  of  tannin  and 
iodoform  in  finely  divided  powders,  administered  by  insufflation 
is  very  effective  (Bartholow  and  Loomis). 

PHLEGMASIA  ALBA  DOLENS. 

Called  also  " milk-leg,"  is  a  swelling  of  one  or  both  lower 
extremities,  occurring  usually  between  the  tenth  and  twentieth 
day  after  confinement,  and  characterized  by  pain,  tension  of  the 
skin,  and  a  milk-like  whiteness  of  the  surface.  Owing  to  its 
color  and  its  supposed  origin,  it  has  received  the  popular  name 
of  milk-leg  (Lusk). 

Causes. — Phlegmasia  is  an  affection  of  the  connective  tissue, 
and  is  associated  in  most,  but  not  in  all,  cases  with  thrombosis 


PHLEGMASIA    ALBA    DOLE^S.  405 

of  the  veins.  In  a  certain  proportion  of  cases  phlegmasia  is 
obviously  the  extension  of  an  inflammation  from  the  genital 
organs  to  the  perineum,  the  nates,  and  the  upper  portion  of  the 
thigh.  When  the  morbid  changes  follow  the  sheaths  of  the 
vessels,  the  walls  of  both  veins  and  lymphatics  thicken,  and  in 
most  cases  secondary  thrombus  formation  results.  A  slowing  of 
the  blood  current,  and  varicose  veins,  predispose  to  thrombosis. 
The  crural  and  its  branches,  the  tibial  and  peroneal  veins  are  the 
ones  usually  involved.  The  intra- venous  coagula  may  start  from 
the  placental  site,  and  thus  obstruct  the  veins.  Thrombus  form- 
ation may  begin  during  pregnancy,  and  is  then  usually  attended 
with  pain  at  the  seat  of  trouble,  and  with  stiffness  in  the  toes  or 
the  dorsum  of  the  foot  (Lusk). 

Symptoms, — Often  phlegmasia  is  preceded  by  gastric  dis- 
turbances, as  lack  of  appetite,  a  furred  tongue,  constipation  and 
chilly  sensations.  Sometimes  the  inflamed  or  thrombosed  veins 
may  be  seen  in  the  popliteal  space  or  upon  the  inner  surface  of 
the  upper  portion  of  the  thigh.  The  first  characteristic  symptom 
is  a  dull,  dragging  pain  in  the  limb,  which  is  increased  by 
motion.  There  may  be  fever.  In  primary  thrombosis  the 
swelling  usually  begins  at  the  ankle,  and  extends  rapidly  upward ; 
in  secondary  thrombosis,  the  swelling  begins  at  the  inguinal  fold 
and  extends  to  the  ankle  (Lusk). 

Termination. — The  ordinary  termination  of  phlegmasia  is  by 
absorption  of  the  thrombus.  The  period  of  extreme  tension  of 
the  skin  lasts  for  from  five  to  eight  days,  and  then  recovery  takes 
place  slowly  requiring  three  to  six  weeks.  In  a  few  cases,  the 
thrombus  may  organize  and  permanently  occlude  the  vessel.  In 
rare  instances  the  process  may  terminate  in  suj^puration  and 
abscess  formation  (Lusk). 

Treatment. — Opium  must  be  given  to  alleviate  the  pain, 
cathartics  to  unload  the  bowels,  quinine,  iron  and  good  food  to 
sustain  the  strength,  and  rest  for  the  swollen  extremity.  The 
limb  should  be  elevated.  Absorption  should  be  promoted  by 
gentle  friction  with  alcoholic  lotions,  and  by  bandaging  the  entire 
limb  evenly  with  a  flannel  roller.  The  patient  should  under  no 
circumstances  be  allowed  to  leave  her  bed  until  well  (Lusk). 


406  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PHTHISIS. 

General  Considerations. — Is  derived  from  a  Greek  word  which 
means  to  pass  or  waste  away.  It  was  formerly  applied  to  all 
wasting  diseases,  irrespective  of  their  causes.  At  the  present 
day  the  term  tuberculosis  is  supplanting  the  word  phthisis,  and 
very  projjerly  too,  since  the  former  expresses  more  accurately 
the  condition  than  the  latter.  By  the  term  tuberculosis,  we  mean 
a  diseased  condition  caused  by  the  introcl  uction  into  the  body  of 
the  tubercle  bacilli.  Specific  nodules  develop,  which  invade  one 
organ  or  the  entire  system.  Tuberculosis  may  be  local  or  general. 
It  is  local  when  limited  to  one  organ,  as  the  lungs,  kidney,  liver 
or  peritoneum.  It  is  general  when  large  numbers  of  tubercle 
bacilli  enter  the  blood  current  and  develop  in  the  various  organs 
of  the  body  a  multitude  of  miliary  tubercles,  called  acute  'miliary 
tuberculosis.  The  tubercle  bacilli  and  their  spores  travel  in  the 
blood  current  and  wherever  they  lodge,  a  tubercle  is  developed. 
The  tubercle  therefore,  is  the  result  of  an  inflammatory  process, 
and  the  infection  which  excites  the  inflammation  is  a  specific 
vegetable  parasite,  called  the  tubercle  bacillis,  which  gains  en- 
trance into  the  body  through  the  respiratory  and  digestive  tract. 
We  finally  conclude  that  tuberculosis  is  an  infectious  disease  and 
that  its  cause  is  the  tubercle  bacillus  (Loomis  and  Flint). 

Tubercle. — Wherever  the  bacillus  lodges  and  finds  conditions 
suitable  for  its  development  and  multiplication,  there  are  found 
in  a  short  time  small,  gray,  translucent  nodules,  looking  like 
particles  of  coarse  sand,  which  are  called  miliary  tubercles. 
Tubercles  are  non- vascular  structures,  no  vessels  have  ever  been 
found  in  them.  They  undergo  caseous  or  cheesy  degeneration. 
As  they  are  non-vascular,  their  centres  are  shut  off  from  nutri- 
tion, and  as  they  are  subjected  to  the  necrotic  action  of  the  tu- 
bercle bacilli,  in  a  short  time  they  die  and  undergo  what  is 
called  "coagulation  necrosis."  A  small  abscess  is  thus  formed, 
and  the  union  of  several  of  these  small  abscesses  form  cavities. 
Instead  of  the  course  just  described,  these  cheesy  masses  may 
become  encapsulated,  calcified,  and  remain  as  inert  masses  for 
an  indefinite  period.  Again,  the  tubercle  may  undergo  fibroid 
changes,  the  tissues  surrounding  the  tubercle  taking  on  a  chronic 


PHTHISIS.  407 

fibroid  inflammation,  the  newly  formed  connective  tissue  con- 
tracts, and  compressing  the  tubercle,  converts  it  into  a  fibrous 
nodule.  This  change  is  most  likely  to  occur  in  the  aged,  and  in 
those  of  a  strong  fibrous  diatheses  (Loomis). 

Questions. — The  following  questions  have  been  asked  and 
answered  by  Prof.  Loomis  : 

1.  "  Can  man  become  infected  with  tubercle  by  eating  tu- 
bercular meat,  or  by  drinking  the  milk  of  tubercular  cows  V 

2.  "May  not  the  tubercle  bacilli  contained  in  the  sputum 
and  other  discharges  from  tubercular  subjects  be  infecting 
agents,  and  thus  render  tuberculosis  a  contagious  disease  V 

3.  "As  the  tubercle  bacilli  preserve  their  vitality  for  along 
time  outside  the  body,  may  not  those  contained  in  the  sputum  of 
tubercular  subjects,  after  the  sputum  becomes  dried  and  pulver- 
ized, be  inhaled  with  the  air  as  dust  particles,  and  set  up  tuber- 
cular processes  in  the  respiratory  organs  of  non-tubercular 
subjects  ?" 

4.  "  As  a  preventative  measure  for  the  spread  of  phthisis, 
should  not  the  sputum  and  other  discharges  be  burned  or  disin- 
fected in  their  fresh  state  V 

Answers. — "Accepting  the  doctrine  that  the  tubercle  bacillus 
is  the  only  cause  of  tuberculosis,  we  are  compelled  to  answer 
these  questions  affirmatively,  and  to  say  that  the  doctrine  of 
heredity  of  tuberculosis  must  be  abandoned,  the  tubercular  taint 
being  nothing  more  than  a  hereditary  enfeeblement,  which  furn- 
ishes a  better  soil  for  the  lodgment  and  development  of  the 
tubercle  bacilli,  or  a  physical  condition  which  is  less  able  to 
resist  their  invasion. 

The  terms  phthisis,  pulmonary  phthisis,  phthisis  pulmonalis, 
pulmonary  consumption,  and  pulmonary  tuberculosis  are  used 
interchangeably. 

Forms  of  Phthisis. — Bartholow  gives  four  forms  of  phthisis: 
1.  The  phthisis  of  caseous  pneumonia.  2.  Tubercular  phthisis. 
3.  Fibroid  phthisis.  4.  Acute  miliary  tuberculosis,  or  general 
tuberculosis.  Loomis  gives  two  distinct  varieties  of  pulmonary 
tuberculosis:  1.  The  acute.  2.  The  chronic.  He  further  di- 
vides the  chronic  into  the  following:  1.  Pneumonic  tuberculosis, 
caseous    pneumonia,    or    catarrhal    phthisis.       2.   Disseminated 


408  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tuberculosis.     3.  Fibrous  tuberculosis,  or  fibroid  phthisis.     He 
also  discusses  acute  miliary  tuberculosis. 

As  respects  the  essential  nature  of  this  disease,  there  is  no 
difference,  all  these  forms  being  characterized  by  the  presence 
and  development  of  the  bacillus  tuberculosis. 

I.  The  Phthisis  of  Caseous  Pneumonia. — Caseous  phthisis 
is  that  form  of  pulmonary  consumption  characterized  by  the 
caseation  or  cheesy  degeneration  of  inflammatory  products  in  the 
lungs,  and  the  subsequent  softening  and  extrusion  of  the  caseous 
matter  with  greater  or  less  destruction  of  the  pulmonary  tissue. 

II.  Tubercular  Phthisis. — Is  that  form  of  pulmonary  con- 
sumption characterized  by  the  deposit  of  gray  tubercle;  by  the 
changes  due  to  such  deposit,  its  softening  and  extrusion,  and 
by  the  greater  or  less  destruction  of  the  proper  tissue  of  the 
lungs. 

Ill  Fibroid  Phthisis. — Is  a  form  of  consumption  charac- 
terized by  hyperplasia  of  the  connective  tissue  of  the  lung  and 
atrophy  and  degeneration  of  its  proper  structure,  with,  finally, 
tubercular  deposits. 

IV.  Acute  Miliary  Tuberculosis. — Is  characterized  by  the 
presence  of  miliary  tubercles  in  most  of  the  organs  of  the  body 
(Bartholow). 

Pathological  Anatomy. — In  most  cases  of  pulmonary  phthisis 
all  of  the  structures  which  compose  the  lungs  are  the  seat  of 
morbid  changes.  There  are  lesions  of  the  bronchi,  of  the  alve- 
olar passages  and  air-cells,  of  the  blood-vessels,  of  the  lymphatic 
vessels,  of  the  interstitial  connective  tissue,  and  of  the  plura. 
The  characteristic  lesions  of  phthisis  are  tubercles  and  inflam- 
matory processes  with  a  tendency  to  caseous  degeneration. 
Another  morbid  change  of  great  importance  is  the  formation 
of  cavities.  The- morbid  appearances  are  so  manifold  that  it 
may  be  said  that  no  two  cases  of  phthisis  are  exactly  alike.  The 
dominating  element  in  the  pathological  anatomy  of  pulmonary 
phthisis  is  tubercle.  Tuberculous  nodules  or  granules  may  be 
seen  with  the  naked  eye,  and  when  young  are  gray  or  translu- 
cent, but  oftener  they  appear  opaque  and  yellowish,  having 
undergone    partial    or    complete    caseous   degeneration.      They 


PHTHISIS.  409 

vary  in  size  from  a  millet- seed   to  a  pea,  and  are   often  larger. 

A  favorite  and  early  situation  for  the  formation  of  miliary 
tubercles  is  in  the  walls  of  the  small  bronchi  or  bronchioles. 
Many  tubercles  are  composed  of  groups  of  air-cells  filled  with 
epithelial  and  lymphoid  cells  with  or  without  giant  cells.  In 
the  majority  of  cases  tubercles  are  formed  primarily  at  the  apex 
of  the  lung.  In  acute  miliary  tuberculosis  miliary  tubercles  are 
found  scattered  throughout  both  lungs.  In  these  cases  the  tuber- 
cle bacilli  are  conveyed  to  the  lungs  by  the  blood- current.  The 
usual  mode  of  access  of  the  tubercle  bacilli  to  the  lungs  is  by  the 
respiratory  passages.  The  production  of  cheesy  pneumonia  is  an 
effect  of  the  tubercle  bacilli.  In  rare  instances  caseous  pneu- 
monia involves  a  whole  lobe  or  a  whole  lung  (phthisis  florida). 
In  most  cases  of  rapid  or  the  so-called  galloping  phthisis 
(phthisis  florida)  more  or  less  extensive  patches  of  caseous  pneu- 
monia form  the  greater  part  of  the  lesions. 

Tubercles  are  non- vascular  structures  and  the  pre-existing 
vessels,  where  the  tubercles  devolop,  become  obliterated,  partly 
by  thrombosis  and  partly  by  an  accumulation  of  epitheloid  and 
lymphoid  cells  in  their  lumen.  The  mucous  membrane  of  the 
bronchi  is  always  inflamed  in  phthisis,  and  contains  tubercles. 
Ulcers  usually  of  tuberculous  origin  are  frequent.  Some  form 
of  peribronchitis  is  a  constant  attendant  of  phthisis.  Inflam- 
mation of  the  interstitial  tissue  of  the  lung,  leading  to 
the  formation  of  new  connective  tissue,  is  called  fibroid 
phthisis.     In  this   case  the  affected  lung  is  diminished  in  size. 

Pulmonary  phthisis  is  always  accompanied  by  pleuritis, 
usually  of  the  dry  form.  The  pleuritis  leads  to  the  formation  of 
vascular  adhesions.  Of  the  non-inflammatory  changes  there  are 
pigmentation  with  coal  particles;  calcification  of  caseous  mate- 
rial; and  localized  and  general  oedema.  After  a  variable  period 
cavities  are  formed  in  the  majoritv  of  cases  of  phthisis.  They 
are  of  two  kinds — those  due  to  dilatation  of  the  bronchi,  bron- 
chiectases, and  those  resulting  from  the  softening  of  cheesy 
material  and  its  removal  through  the  bronchi — ulcerative  cavi- 
ties. The  greater  part  of  a  lobe,  usually  the  upper  lobe,  may  be 
converted  into  a  single  cavity.     The  cavities  are,  as  a  rule,  irreg- 


410  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ular  in  form,  and  are  often  traversed  by  bands  of  fibrous  tissue 
containing  blood-vessels,  the  rupture  of  which  maybe  the  source 
of  dangerous  hemorrhage.  In  cases  of  fatal  haemoptysis  the 
source  of  the  hemorrhage  is  usually  to  be  found  in  an  aneurism 
about  the  size  of  a  pea,  which  projects  from  the  side  of  the  artery 
into  the  cavity.  As  the  expectoration  contains  tubercle  bacilli, 
it  is  common  to  find  tuberculous  lesions  in  the  respiratory  tract 
above  the  lungs,  especially  in  the  larger  bronchi,  the  trachea 
and  the  larynx.  These  lesions  are  usually  in  the  form  of  tuber- 
culous ulcers,  and  are  in  nearly  all  cases  secondary  to  the  pul- 
monary affection.  By  swallowing  sputum  which  contains  the 
tubercle  bacilli,  the  tuberculous  virus  ma}^  gain  access  to  the 
intestinal  tract  and  cause  tuberculous  ulceration  which  is  most 
frequently  in  the  lower  part  of  the  ileum.  From  the  intes- 
tine the  bacilli  may  be  readily  conveyed  to  the  peritoneum,  the 
mesenteric  glands,  the  liver,  etc.  In  most  cases  of  pulmonary 
phthisis  the  primary  infection  takes  place  by  inhalation  of  the 
tubercle  bacilli  in  the  arjex  of  the  lung.  The  bacilli  are  incapa- 
ble of  development  at  a  temperature  below  82.4°  F.  and  above 
107.6°  F.,  the  most  favorable  temperature  for  their  growth  being 
about  that  of  the  human  body  (Flint  and  Bartholow). 

Causes. — The  proof  that  the  tubercle  bacillus  is  the  specific 
cause  of  tuberculosis  may  be  considered  complete.  This  bacillus 
was  discovered  by  Prof.  Koch  in  1882.  The  disease  is  never 
produced  without  this  parasite,  but  the  efficiency  of  this  agent 
depends  on  the  predisposition  or  diathesis.  The  latter  alone  is 
incapable  of  producing  the  disease.  If  the  introduction  of  the 
parasite  into  the  air  passages  could  be  prevented,  the  disease 
would  not  be  produced,  no  matter  how  strong  the  jxredisposition; 
and  on  the  other  hand,  if  the  predisposition  be  wanting,  the  dis- 
ease will  not  be  produced,  no  matter  how  great  the  exposure  to 
the  specific  cause.  When  it  is  considered  that  about  one-seventh 
of  all  human  beings  die  of  phthisis,  it  is  not  difficult  to  account 
for  the  wide  distribution  of  the  tuburculous  virus.  The  bacillus 
tuberculosis  is  not  capable  of  multiplication  outside  of  the  ani- 
mal body,  and  hence  pulmonary  phthisis  is  not  only  an  infecti- 
ous, but  a  contagious  disease.  The  most  fruitful  source  of 
tuberculous  infection  is  to  be  found  in  dried  phthisical  sputum. 


PHTHISIS.  411 

That  it  may  come  from  the  milk  of  tuberculous  cows  is  certain. 
Facts  show  the  tuberculous  predisposition  or  diathesis  in  a  cer- 
tain proportion  of  cases  to  be  congenital  and  inherited.  The 
predisposition  has  a  relation  to  age.  The  disease  is  most  liable 
to  be  developed  between  20  and  30;  then  80  and  40,  10  and  20, 
40  and  50,  50  and  60,  birth  and  10,  60  and  70,  70  and  80,  80  and 
90,  90  and  100.  No  age  is  exempt  from  a  liability  to  the  disease, 
and  it  may  affect  the  foetus  in  utero.  Climate  appears  to  exert 
an  influence  either  for  or  against  the  development  of  the  disease. 
The  prevalence  of  the  disease  is  less  in  climates  either  uniformly 
warm  and  dry  or  uniformly  cold  and  dry  than  in  those  which 
are  moist  and  subject  to  frequent  alterations  of  cold  and  warmth. 
It  is  rare  in  the  torrid  and  frigid  zones,  and  frequent  in  the  tem- 
perate. According  to  Dr.  Hialtelin,  who  resides  in  Iceland,  the 
inhabitants  of  that  country  enjoy  exemption  from  phthisis. 

A  high  altitude  seems  to  afford  protection  against  the  dis- 
ease. In  Alpine  situations  elevated  4000  feet,  tuberculosis  is 
almost  unknown.  The  condition  of  the  soil  of  a  region  favors 
or  is  antagonistic  to  phthisis,  light,  sandy,  porous  soils  are  antag- 
onistic; while  heavy  wet,  hard,  clayey,  impermeable  soil,  and 
sudden  changes  in  the  temperature  are  the  most  favorable  con- 
ditions for  developing  phthisis.  Want  of  sunlight,  defective 
ventilation,  lack  of  exercise,  and  the  depressing  emotions  act  as 
strong  predisposing  causes.  As  regards  season,  the  disease  is 
oftener  developed  during  the  spring  months  and  the  hot  months 
of  summer  than  at  other  seasons  of  the  year.  Tuberculosis  may 
be  communicated  by  the  use  of  dishes,  napkins,  handkerchiefs, 
and  other  personal  belongings  of  phthisical  subjects;  by  the  use 
of  milk  of  tuberculous  women,  and  possibly  by  tuberculous  meat. 
The  scrofulous  or  strumous  constitution  may  constitute  the 
tubercular  diathesis;  but  according  to  Loomis,  phthisis  may  de- 
velop without  this  vice  of  constitution.  Mothers  transmit  phthis- 
ical tendencies  more  certainly  than  fathers.  But  when  one 
parent  alone  is  affected,  the  mother  is  more  apt  to  transmit  to 
the  daughters  than  to  the  sons,  and  vice  versa.  A  phthisical  vice 
of  constitution  may  be  inherited  by  the  children  of  the  aged,  of 
drunkards,  of  those  enervated  by  excesses,  and  of  those  who  at 
the  time  of  the  birth  of  their  children  were  suffering  from  some 


412  A    COJIPEXDimi    OF    PRACTICAL     3IEDICIXE. 

form  of  constitutional  disease,  snch  as  cancer,  syphilis,  or  gout. 
Children  of  consanguineous  marriages  are  especially  liable  to 
pulmonary  phthisis. 

Improper  and  insufficient  food  is  an  influential  cause  of  tu- 
berculosis. The  repugnance  to  fat,  which  is  so  often  manifested 
by  the  phthisical,  is  unfortunate  since  it  is  so  necessary  as  a  force 
furnishing  food.  The  frequency  of  phthisis  in  clerks,  printers, 
tailors,  milliners,  seamstresses  and  factory  employees,  who  live 
in  a  hot,  close,  dust  laden  atmosphere  proves  that  bad  ventila- 
tion, impure  air,  and  an  indoor  life  are  strong  predisposing 
causes.  Of  indoor  workers  those  are  most  liable  to  phthisis  who 
exercise  least  at  their  vocation.  Compositors  suffer  oftener  than 
the  press  hands  in  the  same  room.  Prison  and  cloister  statistics 
show  a  mortality  from  phthisis  of  from  forty  to  fifty  per  cent, 
while  that  among  the  people  at  large  is  only  fifteen  per  cent.  From 
these  considerations,  it  is  evident  that  the  feebleness  of  constitu- 
tion which  predisposes  to  phthisis  can  be  acquired  as  well  as  in- 
herited. Loomis  is  convinced  that  the  phthisical  development 
depends  as  much  upon  the  anti-hygienic  influences  under  which 
childhood  has  been  passed  as  upon  hereditary  tendencies. 

Local  Causes. — Loomis  believes  that  bronchitis  of  the  smaller 
tubes  and  chronic  lobular  (catarrhal)  pneumonia  are  the  starting 
points  of  a  large  number  of  cases  of  phthisis.  The  catarrhal 
condition  of  the  mucous  membrane  in  these  cases  furnishes  the 
favorable  soil  for  the  development  of  bacilli.  Loomis  says, 
"That  pulmonary  phthisis  not  infrequently  dates  from  a  pleurisy 
is  evident  to  every  careful  observer."  He  also  says  that  bronch- 
ial hemorrhage  is  frequently  the  first  and  only  sign  of  phthisical 
development.  The  mechanical  irritation  of  the  bronchi  pro- 
duced by  the  constant  inhalation  of  an  atmosphere  laden  with 
dust  leads  to  phthisis.  The  phthisis  of  knife-grinders,  stone- 
cutters, potters,  and  coal  miners  are  examples  of  this.  Pregnancy, 
instead  of  preventing  phthisis,  predisposes  to  it.  According  to 
Loomis,  emphysema  and  goitre  do  not  afford  immunity  against 
phthisis.  The  notion  that  malaria  and  marsh  fevers  are  antag- 
onistic to  phthisis  is  disproved  by  every  day  experience. 
Patients  in  whom  all  inflammatory  processes  tend  to  necrosis  and 
suppuration  are  more  liable  to   acute  phthisis.     Flint  says  that 


PHTHISIS.  413 

measles  and  typhoid  fever  leave  the  system  in  a  condition  favor- 
able for  the  development  of  tuberculosis.  He  also  asks  "Are 
they  who  suffer  in  early  life  from  a  scrofulous  affection  of  the 
lymphatic  glands  of  the  neck  especially  jDrone  to  pulmonary  tuber- 
culosis in  after  life"?  He  answers  this  question  in  the  negative, 
and  says  "  Assuming  tuberculosis  and  the  scrofulous  cachexia  to 
be  identical  as  has  been  proved  by  the  presence  in  both  of  the 
bacillus  tuberculosis,  it  would  seem  that  the  predisposition  is,  as 
it  were,  exhausted  by  the  affection  in  the  glands  of  the  neck,  and 
that  afterward  it  is  not  likely  to  occur. 

Flint  believes  that  bronchitis,  acute  or  chronic,  has  no  ten- 
dency to  eventuate  in  phthisis,  and  that  acute  pleurisy,  lobar 
pneumonia,  and  bronchial  hemorrhage  have  no  causative  relation 
to  pulmonary  phthisis.  The  opinion,  which  is  held  by  some 
writers,  that  chronic  pharyngitis  (which  is  an  exceedingly  com- 
mon affection  in  this  part  of  the  world),  has  a  tendency  to  event- 
uate in  pulmonary  phthisis,  is  erroneous  according  to  Prof.  Flint. 
The  sebum-like  matter  which  is  liable  to  accumulate  in  the 
glands  of  the  tonsils  and  coughed  up  in  the  form  of  round  hard 
pellets,  is  sometimes  mistaken  for  tubercles.  They  emit  a  fetid 
odor  when  touched.  Bartholow  believes  that  one  of  the  factors 
in  determining  tuberculosis  of  the  lungs  is  a  badly  formed  thorax. 
Flint  does  not  believe  this.  Bartholow  says:  "Although  the 
bacillus  tuberculosis  has  been  widely  accepted  as  the  cause  of 
phthisis,  yet  opposition  is  developing  in  various  quarters."  Dr. 
Spina,  of  Vienna,  chief  assistant  to  Strieker,  opposes  Koch  at  all 
points,  and  maintains  that  the  bacillus  has  not  a  constant  form, 
but  varies  with  the  tissue  and  local  condition;  that  it  is  not 
essential  to  the  tubercular  process,  and  that  it  is  frequently 
absent  in  undoubted  tubercular  disease.  From  the  practical 
side,  Koch's  theory  has  received  a  severe  blow  in  two  cases, 
which  have  recently  occurred  at  Nothnagel's  clinic.  In  both 
tuberculosis  was  diagnosticated,  because  the  bacilli  were  detected 
in  the  sputa.  Yet,  on  post  mortem  examination,  both  were  ascer- 
tained to  be  examples  of  bronchiectasis,  and  no  tubercles  ex- 
isted at  any  point.  It  follows,  from  these  facts,  that  the  para- 
sitic nature  of  tubercular  phthisis  must  be  regarded  as  sub 
judic&    The  physician  should  not  rush  to  the  conclusion  that  the 


414  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

parasitic  nature  of  phthisis  is  proved  (Flint,  Loomis  and  Bartho- 

low). 

Symptoms. — Phthisis  presents  itself  in  a  chronic  and  in  an 
acute  form.  The  chronic  variety  is  by  far  the  most  frequent.  It 
is  essentially  the  "consumption"  which  is  such  a  scourge  to  the 
human  race.  The  harassing  cough  by  day  and  by  night;  the 
impaired  appetite  and  disturbed  digestion;  the  loss  of  blood  from 
the  lungs;  the  steadily- augmenting  debility;  the  short  breathing; 
the  exhausting  night  sweats;  the  hectic  fever;  the  deceptive 
blush  which  this  imparts  to  the  cheek;  the  increased  lustre  of 
the  eye;  the  singular  hopefulness;  the  temporary  improvements; 
the  relapses;  and  the  greater  vividness  of  the  imagination,  so 
strongly  contrasting  with  the  waning  frame — are  phenomena 
with  which  sad  experience  has  made  not  only  every  physician 
but  many  a  fireside  familiar  (DaCosta).  The  most  constant  of 
all  these  symptoms  are  the  hemorrhage,  the  cough  and  the  ema- 
ciation. Phthisis  is  often  remarkably  insidious  in  its  develop- 
ment. 

Cough — Of  the  pulmonary  symptoms,  the  first  which  occurs 
is  cough.  The  cough  is  at  first  and  for  some  time  slight,  dry, 
hacking  and  perhaps  it  excites  little  or  no  attention.  It  contin- 
ues throughout  the  whole  course  of  the  disease.  It  may  exist 
before  there  are  any  physical  signs,  and  then  there  is  little  or  no 
expectoration.  It  may  amount  only  to  a  "clearing  of  the  throat." 
The  severity  of  the  cough  without  expectoration  is  a  measure  of 
the  extent  to  which  the  pleura  is  involved.  The  younger  and 
more  excitable  the  patient,  the  more  paroxysmal  is  the  cough. 
It  is  usually  worse  in  the  morning  on  rising  or  just  after  lying 
down  at  night.  Lying  on  the  affected  side  often  brings  on  a  vio- 
lent paroxysm.  Some  cough  after  the  slightest  exertion.  In  se- 
vere poroxysms  of  coughing,  in  the  last  straining  effort  to  dis- 
lodge the  sputa,  vomiting  is  excited,  an  accident  very  apt  to  oc- 
cur after  meals.  The  cough  in  the  second  stage  usually  becomes 
prominent.  It  may  be  less  irritable  and  more  exclusively  for  ex- 
pectoration. In  advanced  phthisis,  where  cavities  have  formed, 
the  cough  becomes  "hollow  "in  character.  The  cough  is  very 
troublesome  if  the  contents  of  the  cavities  are  not  easily  evacu- 
ated (Bartholow,  DaCosta,  Flint  and  Loomis). 


PHTHISIS.  415 

Expectoration. — May  accompany  cough  from  its  commence- 
ment. At  first  it  is  tenacious,  glairy,  frothy  and  mucous.  As 
the  disease  advances  it  thickens.  It  becomes  greenish  in  color, 
streaked  with  yellow,  and  "nummular"  (consisting  of  large 
greenish  masses  of  a  rounded  form,  which  masses  do  not  sink  in 
the  cup  containing  them,  but  float  imperfectly  in  a  thin  serum.) 
This  expectoration  is  not  pathognomonic  of  phthisis,  as  it  may 
occur  in  chronic  bronchitis.  Dots  and  streaks  of  blood  in  ca- 
tarrhal sj3uta  indicate  a  recent  lobular  pneumonia.  The  sputa 
in  the  earlier  stages — often  for  months — are  muco- purulent. 
When  shreds  of  elastic  tissue  are  found,  it  indicates  softenino- 
and  destruction  of  lung  tissue.  As  cavities  form,  the  sputa  be- 
comes more  purulent,  sometimes  being  composed  wholly  of  fluid 
pus,  which  may  be  fetid  and  greenish  and  contain  small  masses 
of  cheesy  matter  and  the  tubercle  bacilli.  In  the  last  stages  of 
consumption  the  sputa  may  have  a  dirty- grayish  aspect.  The 
quantity  of  ex23ectoration  is  very  variable,  amounting  in  some 
cases  to  only  a  few  ounces,  and  in  other  cases  to  a  pint  or  more 
daily.  Sometimes  the  expectoration  presents  a  thick,  opaque 
appearance  like  that  of  pea- soup  or  gruel,  or  it  may  resemble 
boiled  rice.  The  expectoration  is  usually  more  abundant  in  the 
morning  than  at  any  other  time,  owing  to  its  having  accumulated 
during  sleep.  Occasionally  the  matter  expectorated  and  the 
breath  of  the  patient  emit  considerable  fetor,  due  to  putref ac- 
tion of  the  contents  of  cavities  (Bartholow,  DaCosta,  Flint  and 
Loomis). 

Haemoptysis. — Is  a  very  important  symptom  of  phthisis,  and 
may  occur  during  any  stage  of  the  disease.  It  may  be  the  first 
symptom.  Haemoptysis  is  more  frequent  in  the  first  stage,  than 
in  the  second.  The  blood  may  simply  streak  the  sputa,  or  a 
pound  or  more  may  be  expectorated  at  onetime.  The  blood  is 
bright  colored,  more  or  less  aerated,  and  comes  up  with  cough- 
ing; but  a  sudden  large  hemorrhage  may  j^our  up  in  a  stream 
aud  be  ejected  by  the  nose  as  well  as  the  mouth.  Hemorrhages 
that  occur  in  the  early  stage  of  pulmonary  phthisis  are,  iu  the 
majority  of  instances,  bronchial,  and  the  blood  expectorated  is 
arterial  in  color.  When  streaks  of  blood  appear  in  the  sputa, 
the  bleediuo;  usually  comes  from  the  vessels  of  the  alveolar  walls. 


416  A    COMPENDIUM    OF    PEACTICAL     MEDICIJNTE. 

Profuse  hemorrhage  in  the  later  stages  of  phthisis  have  their 
origin  in  cavities  in  the  lung  substance.  Haemoptysis  usually 
comes  on  with  coughing.  There  is  a  sensation  as  if  a  fluid  were 
trickling  underneath  the  sternum,  and  there  may  be  cardiac  pal- 
pitation, oppressed  breathing,  and  a  peculiar  sweetish  and  saltish 
taste  in  the  mouth.  For  some  time  after  the  primary  hemor- 
rhage, blood  is  coughed  up,  and  the  color  of  the  spitting  becomes 
darker.  Sometimes  without  warning  there  is  sudden  filling  of 
the  mouth  with  hot  arterial  blood.  In  advanced  phthisis 
hemorrhage  may  be  the  immediate  cause  of  death. 

According  to  English  writers,  there  may  be  a  hemorrhagic 
phthisis.  In  this  variety,  an  apjoarently  healthy  man  has  a  sud- 
den and  profuse  hemorrhage,  recurring  daily  for  some  time,  fol- 
lowed by  cough  and  slight  expectoration  for  a  few  days,  with  no 
physical  signs  of  consolidation.  These  cases  often  continue  for 
years  without  any  other  phthisical  symptoms,  but  sooner  or  later 
phthisis  is  developed.  Tubercular  disease  of  the  vascular  walls 
is  the  primary  and  chief  event  in  such  cases.  Haemoptysis  may 
occur  in  persons  who  do  not  have  phthisis  at  the  time,  or  who  do 
not  become  phthisical  afterwards.  A  pulmonary  hemorrhage 
may  be  vicarious  of  the  menstrual  flow,  and  it  may  be  determined 
by  the  sudden  arrest  of  hemorrhoidal  bleeding  (Bartholow,  Flint 
and  Loomis). 

Pain. — Pain  in  the  chest  does  not  belong  to  the  disease 
per  se;  but  it  is  liable  to  occur  at  times  more  or  less  frequently 
during  the  first  stage  of  the  disease,  and  is  due  to  circumscribed 
pleurisy.  Sometimes  the  pain  is  sharp,  lancinating,  or  stich-like, 
referred  to  the  summit  of  the  chest,  and  frequently  shooting 
beneath  the  scapula.  The  pleurisy  is  of  the  dry  form,  and  seldom 
causes  severe  pain,  but  rather  a  sense  of  tightness  and  constric- 
tion on  taking  a  full  inspiration.  Intercostal  neuralgia  is  fre- 
quent and  may  be  confounded  with  the  pain  of  a  localized 
pleurisy.  Pain  on  swallowing  usually  announces  the  co- exist- 
ence of  laryngeal  phthisis. 

Respirations. — Are  usually  increased  in  frequency.  It  is 
apparent  especially  on  exercise.  The  accelerated  breathing  is 
due  to  the  fever,  to  the  diminished  breathing  area,  to  bronchial 
obstruction,  and  to  pain  in  the  chest.    Anaemia  and  heart- failure 


PHTHISIS.  417 

may  also  cause  it.  During  the  whole  course  of  fibroid  phthisis, 
shortness  of  breath  on  exertion  is  a  constant  symptom. 

Circulation. — During  the  first  stage  more  or  less  accelera- 
tion of  the  pulse  is  the  rule,  and  is  an  important  diagnostic  symp- 
tom. If  the  pulse  be  frequent  the  disease  is  likely  to  be  rapidly 
progressive.  In  chronic  phthisis  the  pulse  is  always  feeble.  It 
is  accelerated  by  slight  exciting  causes.  In  the  early  stage  of 
fibroid  phthisis  the  pulse  is  rarely  over  100.  In  the  last  stage  of 
all  varieties  of  phthisis  the  pulse  becomes  very  rapid  and  feeble. 
The  pulse  is  soft  and  compressible  and  the  arterial  tension  low 

Fever. — Rise  in  temperature  is  so  constant  a  symptom  of 
phthisis  that  it  has  led  to  the  expression,  "there  is  no  consump- 
tion without  fever."  The  fever  course  may  be  different  in  dif- 
ferent cases.  The  usual  type  of  fever  in  the  beginning  is  the 
quotidian.  There  is  a  daily  morning  remission  and  an  evening 
exacerbation  terminating  in  a  sweat,  the  so-called  hectic  fever 
(septicemic  fever).  Hectic  fever  may  occur  in  any  stage  of 
phthisis,  but  is  usually  confined  to  the  stage  of  softening  and 
excavation.  It  has  three  stages:  first,  a  well-marked  chill  or 
chilly  sensation,  lasting  for  a  half  to  one  hour;  second,  the  chill 
is  followed  by  dryness  and  heat  of  the  surface,  the  temperature 
rising  from  102°  to  104°  F.  The  face  assuming  a  peculiar  bril- 
liant appearance,  and  the  cheeks  having  a  peculiar  rosy  tint 
called  the  "  hectic  flush,"  and  third,  the  sweating  stage  comes  on 
sometime  in  the  night.  The  night-sweats  are  usually  profuse 
and  exhausting  and  always  indicate  the  existence  of  hectic  fever. 
The  chills  and  fever  may  be  absent  but  the  sweats  are  constant. 
Sometimes  there  is  a  marked  sensation  of  burning  in  the  soles 
and  palms. 

The  type  of  fever  may  be  double  quotidian  (two  paroxysms 
of  fever  each  day).  In  some  cases  the  temperature  in  the 
morning  may  be  subnormal,  only  reaching  normal  in  the  even- 
ing; in  others  the  rise  begins  at  2  p.  m.,  and  continues  until  8 
p.  m.,  and  then  falls  until  5  in  the  morning.  As  cavities  form, 
-the  afternoon  rise  occurs  later,  at  10  to  12  at  night.  Toward  the 
end  of  the  disease  the  fever  type  resembles  that  of  pyaemia.  A 
normal  temperature  denotes  that  the  disease  is  stationary  or  non- 
progressive,    and    a    steady    and    continuous   high    temperature 


418  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

denotes  that  it  is  progressive.  The  cliills,  the  fever  and  perspi- 
ration may  occur  with  such  regularity  that  the  patient  is  supposed 
to  have  intermittent  fever.  In. fibroid  phthisis  the  temperature 
rarely  rises  more  than  a  degree  or  two  above  the  normal.  In 
the  absence  of  local  symptoms,  the  thermometer  alone  may 
detect  pulmonary  phthisis  in  the  aged  (Bartholow,  Flint  and 
Loomis). 

Emaciation. — Is  an  early  and  constant  symptom  of  phthisis; 
but  it  is  not  always  jDrogressive.  Fever  is  the  chief  cause  of  the 
wasting  and  pallor  that  are  so  common  in  all  varieties  of 
phthisis.  The  higher  the  average  fever,  the  more  rapid  the  ema- 
ciation. Wasting  may  occur  before  any  local  trouble  of  the 
lungs  is  detected.  Emaciation  may  not  be  continuous  in  all 
cases;  there  are  periods  when  the  patient  may  even  regain  lost 
weight  and  muscular  strength.  The  anorexia,  dysj>epsia,  diar- 
rhoea, profuse  expectoration  and  haemoptysis  are  all  causes  of 
tbe  emaciation.  The  wasting  occurs  not  only  in  the  fat  and 
muscle,  but  in  the  organs  and  blood  as  well.  Slow,  gradual 
wasting  belongs  to  the  history  of  fibroid  phthisis  (Loomis). 

Disturbances  in  the  Alimentary  Tract. — In  some  cases  there 
is  almost  entire  loss  of  appetite,  and  even  a  repugnance  to  food. 
This  is  an  unfavorable  feature  of  the  disease.  Disorder  of  diges- 
tion is  sometimes  so  prominent  as  to  appear  to  be  the  chief 
malady.  There  may  be  nausea  and  vomiting,  and  pain  in  the 
stomach  due  to  gastric  catarrh.  Diarrhoea  may  occur  in  the  first 
stage.  It  may  exist  with,  and  without  a  tuberculous  affection  of 
the  intestinal  canal.  Persisting  or  frequently  recurring  diarrhoea,, 
accompanied  by  cough,  be  the  latter  never  so  slight,  should  ex- 
cite suspicion  of  pulmonary  phthisis.  Tuberculosis  of  the  intes 
tines  results  from  swallowing  the  expectoration.  Tuberculous 
ulcerations  are  sometimes  found  in  the  large  as  well  as  in  the 
small  intestine.  The  ulcerations  may  lead  to  circumscribed  per- 
itonitis. Perforation  of  the  intestine  may  take  place.  The  ulcer- 
ation may  cause  intestinal  hemorrhage.  Diarrhoea  is  a  more 
prominent  symptom  in  the  second  stage.  It  is  usually  most 
severe  at  night.  If  profuse,  and  watery,  it  is  called  colliquative 
diarrlicea.  Colliquative  diarrhoea  occurs  at  an  advanced  period 
of  the  disease,  although  tuberculosis  of  the  intestine  does  not 


PHTHISIS.  419 

exist.  There  may  be  tympanites.  Hemorrhoids  and  fistula  in 
ano  are  frequent  troublesome  complications  of  phthisis,  and 
should  always  be  relieved  by  surgical  interference  in  the  early 
stages  of  the  disease.  The  cure  of  a  fistula  in  ano  or  the  heal- 
ing of  an  old  ulcer  is  often  followed  by  phthisical  developments 
(Flint  and  Loomis). 

Menstruation.-1— Arrest  of  menstruation  is  a  very  frequent 
occurrence  in  females  who  are  consumptive.  In  young  females 
this  is  sometimes  the  first  noticeable  symptom.  In  advanced 
phthisis,  it  indicates  extreme  exhaustion,  and  is  often  followed 
by  a  more  rapid  progress  of  the  disease  (Loomis). 

Hoarseness. — Or  huskiness,  and  sometimes  extinction  of  the 
voice  denote  laryngitis,  which  may  be  developed  in  the  first  as 
well  as  in  the  second  stage.  Its  occurrence  is  presumptive  proof 
of  pulmonary  phthisis,  the  latter,  as  a  rule,  existing  prior  to  the 
laryngitis  (Flint).  The  pharynx  is  sometimes  the  seat  of  tuber- 
culous processes.  A  less  constant  symptom  is  the  red  line  around 
the  border  of  the  gum.  In  some  persons  this  gingival  line  is  a 
mere  streak;  in  others  it  is  more  than  a  line  in  breadth  (Da- 
Costa). 

Clubbed  dingers . — The  end  of  the  finger  is  somewhat 
clubbed.  The  nails  are  curved  and  become  claw  like,  prominent 
in  the  centre,  depressed  at  the  sides,  their  surface  slightly 
cracked,  their  appearance  bluish.  This  peculiar  appearance  is 
characteristic  of  phthisis,  but  is  not  pathognomonic.  A  similiar 
nail  is  seen  in  chronic  pleurisy,  and  in  diseases  of  the  heart. 
Clubbed  fingers  are  found  in  about  twenty- five  per  cent,  of  the 
cases. 

Shin. — Is  pale  and  traversed  by  prominent  blue  lines.  The 
hair  becomes  thin,  dry,  gray  and  falls  out.  (Edema  of  the  feet 
and  legs  is  a  frequent  symptom  of  the  second  stage,  denoting  no- 
table failure  of  the  circulation.  At  first  it  disappears  on  lying 
down,  but  at  length  it  is  permanent.  Its  occurrence  indicates 
that  a  fatal  issue  is  not  far  distant  (Flint  and  Loomis). 

Cerebral  Symptoms. — Are  rarely  pronounced  in  any  stao-e 
of  phthisis.  There  is  no  chronic  disease  in  which  the  mind  is  so 
clear.  The  feelings  are  usually  cheerful  and  buoyant.  Patients 
are  hopeful  respecting  their  condition,  and  are  readily  persuaded 


420  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

that  they  are  improving,  and  hence  they  fall  an  easy  prey  to 
quacks.  They  sometimes  dislike  to  be  told  the  truth,  and  take 
offense  at  an  intimation  that  they  are  consumptive.  The  expec- 
tation of  improvement,  prolonged  life,  or  even  recovery,  amounts 
in  some  cases  to  an  insane  delusion.  Patients  are  sometimes 
occupied  in  forming  plans  for  the  future  when  it  is  obvious  to  an 
observer  that  they  are  on  the  verge  of  the  grave  (Flint  and 
Loomis). 

Physical  Signs. — 1.  Of  the  stage  of  consolidation:  Inspection 
reveals  diminished  expansion,  on  inspiration,  in  the  supra -and 
infra- clavicular  regions  of  the  affected  side.  Palpation  shows 
more  distinctly  the  loss  of  expansion  on  the  affected  side,  and 
increase  of  vocal  fremitus  over  the  consolidated  lung.  Percus- 
sion elicits  relative  dullness  and  sometimes  even  flatness.  If  the 
consolidation  is  slight,  the  percussion  sound  may  remain  normal. 
To  recognize  a  slight  consolidation  at  the  apex  of  the  lung,  it  is 
important  to  percuss  from  the  trachea  rather  than  toward  it.  In 
all  cases  percussion  should  be  performed  at  the  end  of  a  full  in- 
spiration and  at  the  end  of  a  full  expiration.  Auscultation 
shows  increase  of  vocal  resonance.  Over  the  affected  portion, 
the  respiratory  sounds  maybe  feeble  or  exaggerated,  interrupted 
or  wavy.  In  addition  there  are  certain  adventitious  sounds  or 
■rales.  The  earliest  of  these  audible  is  a  fine,  dry,  crackling 
sound  (sub -crepitant)  appearing  at  the  end  of  inspiration. 

The  sub  crepitant  rales  heard  within  a  circumscribed  space 
at  the  summit  of  the  chest  on  one  side  are  highly  significant  of 
tubercle.  They  proceed  from  secondary  circumscribed  bronchi- 
tis. A  crepitant  rale,  in  like  manner  limited  to  a  small  space  at 
the  summit  on  one  side,  has  the  same  significance,  being  due  to 
secondary  circumscribed  pneumonitis.  Crumpling  and  crackling 
sounds  are  significant,  provided  they  be  limited  to  the  summit 
on  one  side.  A  pleural  friction  sound  limited  to  the  summit  on 
one  side  denotes  a  secondary  circumscribed  pleuritis. 

2.  Of  the  stage  of  softening  .and  excavation. — Inspection 
shows  a  greater  frequency  of  respiration  and  a  more  marked  de- 
pression above  and  below  the  clavicle  on  the  affected  side,  as  well 
as  increased  difficulty  in  local  expansion.  In  fibroid  phthisis  the 
retraction  is  more  marked  than  in  any  other  variety.     Palptaion 


PHTHISIS.  421 

shows  diminished  expansion  of  the  affected  side,  on  forced  in- 
spiration. Vocal  fremitus  is  increased.  Percussion  shows  more 
uniform  and  widely  spread  dullness.  Auscultation  shows  bron- 
chial breathing,  and  bronchophony  becomes  more  distinct. 
Numerous,  moist,  crackling  rales  are  heard.  When  cavities  form, 
hi spert ion  shows  greater  depression  in  the  infra- clavicular  region 
and  less  expansive  movements.  Pal/pdtion  shows  intensified 
vocal  fremitus  over  large  cavities  containing  air  and  communi- 
cating with  a  bronchus.  Percussion  gives  a  tympanitic  reso- 
nance, and  the  varieties  of  this  resonance,  called  "cracked- pot11 
and  amphoric,  denotes  cavities.  If  the  cavity  is  filled  with  liquid 
there  will  be  dullness  on  percussion.  Auscultation.  Over  small 
cavities,  cavernous  respiration  will  be  heard.  Over  large  cavities 
near  the  surface  amphoric  respiration  will  be  heard.  The  incom- 
ing air  may  bubble  up  and  cause  gurgles  (Loomis  and  Flint). 

The  Diagnostic  Points  Pertaining  to  Symptoms. — 1.  Cough  and 
expectoration,  not  succeeding  an  attack  of  acute  bronchitis,  and 
not  connected  with  chronic  pharyngitis,  the  cough  at  first  dry 
and  expectoration  small  and  transparent,  and  becoming  gradually 
more  abundant  and  opaque.  2.  Stitchpains  at  the  summit,  not 
connected  with  intercostal  neuralgia.  3.  Chills  not  referable  to 
malaria.  4.  Hcemopjtysis.  5.  Accelerated  breathing.  6.  Loss  of 
weight.  7.  Pallor  or  anosmia  not  otherwise  explicable.  8. 
Hoarseness,  or  huskiness  of  the  voice  proceeding  from  chronic 
laryngitis.  9.  Chronic  peritonitis  not  traumatic.  10.  Suppres- 
sion of  the  menses.  11.  Buoyancy  of  mind  instead  of  despond- 
ency (Flint). 

Differential  Diagnosis. — -The  diagnosis  of  pulmonary  phthisis 
rests  mainly  upon  an  examination  of  the  sputum  and  upon  physi  - 
cal  signs.  Incipient  phthisis  may  be  confounded  with  atonic 
dyspepsia.  A  cough  may  be  present  in  atonic  dyspepsia,  the  so- 
called  stomach  cough;  but  in  this  case  there  is  no  irritation  about 
the  air- passages.  In  advanced  phthisis,  hectic  fever  may  be  con- 
founded with  intermittent.  In  phthisis,  the  fever  has  been  pre- 
ceeded  by  a  period  of  cough,  and  loss  of  flesh  and  strength, 
whereas  in  intermittent,  these  symptoms  have  followed  the  access 
of  fever.  In  phthisis  there  is  not  enlarged  spleen  and  the  hectic 
is  not  arrested  by  large  doses  of  quinine.     Laryngeal   symptoms 


422  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

are  often  so  pronounced  in  the  beginning  as  to  obscure  the  pul- 
monary affection.  When  tubercular  deposits  occur  in  the  larynx, 
the  tone  and  quality  of  the  voice  are  quickly  affected,  so  that  the 
larynx  may  seem  to  be  the  only  seat  of  tubercular  deposit.  The 
coexistence  of  pulmonary  disease  ought  to  be  suspected,  because 
of  the  relation  known  to  obtain  between  them. 

Acute  phthisis  may  be  mistaken  for  croupous  pneumonia, 
bronchiectasis  and  capillary  bronchitis.  In  pneumonia  the  pro- 
longed ushering  in  chill,  the  continuous  high  temperature,  the 
characteristic  sputum,  the  dullness  limited  to  a  lobe,  and  the 
pneumonic  countenance,  are  symptoms  which  readily  distinguish 
it  from  acute  phthisis.  Bronchiectasis  accompanied  by  wasting, 
fetid  expectoration,  hamioptysis,  and  night  sweats  with  the  phys- 
ical signs  of  consolidation,  may  well  be  mistaken  for  the  ad- 
vanced stage  of  acute  phthisis.  But  in  phthisis  the  signs  of  con- 
consolidation  precede  those  of  cavities;  in  bronchiectasis  they 
follow  them.  Fever  and  emaciation  are  always  greater  in 
phthisis  than  in  bronchiectasis.  In  capillary  bronchitis  there  is 
no  dullness  on  percussion,  subcrepitant  rales  are  heard  on  both 
sides  of  the  chest,  and  there  is  no  bronchial  character  to  the  re- 
spirations. The  early  stage  of  chronic  phthisis  may  be  con- 
founded with  bronchitis,  pulmonary  infarction,  pleurisy,  acute 
lobar  pneumonia,  anaemia  with  cough  and  expectoration  and 
cancer  of  the  lung.  The  evidence  of  consolidation  of  lung-tissue 
is  essential  to  the  diagnosis  of  phthisis.  So  long  as  bronchitis  is 
accompanied  by  a  temperature  of  100°  F.,  and  the  physical  signs 
show  that  the  bronchitis  is  general,  phthisis  is  readily  excluded; 
but  if  the  temperature  rises  to  103°  F.,  and  localized  crepitant 
rales  develop  at  the  apex  of  either  lung,  accompanied  by  dullness 
on  percussion  over  the  seat  of  the  rales  with  a  bronchial  charac- 
ter to  the  respirations,  then  there  is  reason  to  believe  that  phthisis 
is  being  developed.  The  diagnosis  between  chronic  bronchitis  and 
fibrous  phthisis  rests  upon  the  evidences  of  consolidation  and 
retraction  in  phthisis,  and  their  absence  in  bronchitis.  Pulmon- 
ary infarctions  are  attended  by  haemoptysis  and  localized  areas 
of  dullness.  Heart  disease  is  their  chief  cause.  The  blood  ex- 
pectorated in  phthisis  is  of  a  bright  scarlet  color;  in  infarctions 
it  is  dark  and  in  the  form  of  coagula.     Infarctions  are  most  fre- 


PHTHISIS.  423 

quently  situated  in  the  lower  lobes;  in  phthisis  the  dullness  is 
apical.  In  pleurisy  with  effusion,  flatness  will  exist  from  the 
base  of  the  lungs  to  the  level  of  the  fluid;  the  line  of  flatness 
will  change  with  a  change  in  the  position  of  the  patient.  The 
cough  is  more  hacking  and  is  not  accompanied  by  expectoration, 
and  vocal  fremitus  is  diminished  or  absent.  A  localized  pleurisy 
at  the  apex  of  the  lung,  not  the  result  of  a  general  pleurisy,  is 
indicative  of  tubercular  development.  A.namiia  with  cough  and 
expectoration  is  attended  by  no  febrile  symptoms,  and  by  none 
of  the  physical  evidences  of  pulmonary  consolidation.  In  cancer 
of  the  lung  there  is  usually  bulging  of  the  chest  at  the  seat  of 
the  cancerous  development;  in  phthisis  there  is  retraction.  In 
cancer  the  temperature  is  often  subnormal;  in  phthisis  it  is  more 
or  less  elevated.  The  currant-jelly  expectoration  of  cancer  is 
diagnostic.  Pain  is  constant  in  cancer  and  intermittent  in 
phthisis. 

The  difference  between  caseous  and  tuberculous  phthisis  is  as 
follows:  Tubercular  phthisis  is  distinctly  hereditary;  caseous 
phthisis  is  not  hereditary,  but  occurs  in  the  scrofulous.  Tuber- 
cular phthisis  occurs  at  all  ages;  caseous  from  youth  to  middle 
age.  Tubercular  phthisis  occurs  insidiously  with  catarrh  of  the 
bronchi  and  larynx;  caseous  results  from  acute  inflammations  of 
the  bronchi  and  lungs.  In  tubercular  phthisis  the  lesions  are 
apt  to  be  on  both  sides;  in  caseous  on  one  side.  The  laryngeal 
symptoms  are  much  more  common  in  tubercular  than  in  caseous 
phthisis.  Fibroid  phthisis  is  distinguished  from  the  other  forms 
by  its  slow  progress,  by  the  long  period  of  bronchial  troubles 
before  the  pulmonary  lesions  begin  and  by  the  merely  purulent 
expectoration  (Bartholow,  Flint  and  Loomis). 

Prognosis. — The  duration  of  phthisis  is  extremely  variable. 
In  the  vast  majority  of  cases  it  is  essentially  a  chronic  affection, 
but  sometimes  it  runs  a  rapid  course  destroying  life  in  a  few 
weeks.  The  disease  in  such  cases  has  been  known  as  "galloping 
consumption,"  or  phthisis  florida,  or  acute  phthisis.  The  prog- 
nosis of  acute  phthisis  is  always  unfavorable.  Its  average  dura- 
tion is  from  five  weeks  to  five  months.  Flint  distributes  fatal 
cases  into  groups  as  follows:  "One  group  will  consist  of  cases  in 
which  the  disease  continues  from  three  to  six  months;  in  another 


424  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

group  death  takes  place  between  six  months  and  a  year;  and  in 
a  third  group  the  career  extends  from  one  to  two  years;  and  in 
another  group  the  fatal  termination  is  held  in  abeyance  for  many 
years."  Flint  says,  "  The  generations  of  bacilli  may  die  out  or 
be  destroyed,  and  the  tuberculous  products  may  be  either  ab- 
sorbed or  calcification  may  occur.  Cavities  may  completely 
cicatrize.  In  these  modes  complete  recovery  may  take  place. 
Cavities  may  exist  without  any  fresh  products,  giving  but  little 
inconvenience  for  an  indefinite  period,  and  even  through  a  long 
life."  Of  670  cases  analyzed  by  Flint,  44  ended  in  recovery,  and 
in  31  cases,  the  disease  became  non-progressive.  He  claims  the  es- 
tablishment of  the  fact  that  in  a  certain  proportion  of  cases 
phthisis  is  self  limited.  The  most  rational  explanation  of  the 
manner  in  which  this  disease  ends  by  self-limitationisto  suppose 
that  the  conditions  which  are  essential  for  the  multiplication  of 
the  bacilli  and  which  constitute  the  tuberculous  predisposition  or 
diathesis,  after  a  time  cease  to  exist.  The  vegetable  parasite  is 
destroyed  because  the  soil  becomes  incapable  of  maintaining 
longer  its  existence.  Persistent  frequency  of  the  pulse,  fever, 
anorexia,  and  progressive  emaciation  oppose  reliance  on  self- 
limitation.  In  proportion  as  phthisis  is  well  tolerated  there  is 
room  for  hoping  that  it  will  prove  self-limited. 

ITwmoptysis  is  very  rarely  an  immediate  cause  of  death.  The 
disease  proves  fatal  generally  by  asthenia.  Bartholow  says, 
"Phthisis  is  the  great  enemy  of  the  human  race  since  nearly  two - 
sevenths  of  the  deaths  from  all  causes  are  due  to  this  disease." 
He  also  says,  "  Cures  are  now  not  uncommon." 

Under  prognosis  Loomis  says,  "Chronic  pulmonary  phthisis 
is  not  necessarily  a  fatal  disease.  Its  morbid  processes  niay  be 
arrested  in  the  early  stage  or  in  the  stage  of  cavities  by  proper 
treatment.  Recovery  has  occurred  in  one- sixth  of  my  recorded 
cases  during  the  past  ten  years.  The  average  duration  of 
phthisis  is  three  years  and  four  months.  Phthisis  can  in  no  sense 
be  regarded  as  a  self-limited  disease.  Some  cases,  after  a  period 
of  activity,  become  stationary  and  then  recover;  others  slowly 
but  steadily  progress  to  a  fatal  termination;  others  again  pursue 
a  more  rapid  and  fatal  course."  The  prognosis  is  unfavorable 
when  there  is  a  strong  hereditary  tendency,   wheu  phthisis   de- 


PHTHISIS.  425 

velops  early  in  life,  when  scrofulous  or  glandular  disease  has  ex- 
isted in  childhood,  when  the  patient  is  narrow- chested,  when  the 
ordinary  pulse  rate  is  high,  and  when  there  is  great  variation  in 
weight  without  any  apparent  cause.  Frequent  haemoptysis  in  an 
early  stage  of  the  disease  is  not  unfavorable.  When  oedema 
of  the  feet  and  lower  extremities  comes  on  in  advanced  phthisis, 
the  j>rognosis  is  very  unfavorable,  and  a  fatal  issue  is  not  far  off. 
Advanced  cases  may  die  suddenly  from  heart  failure  or  syncope. 
The  majority  waste  to  a  skeleton,  but  the  mind  is  perfectly  clear 
and  the  patient  is  hopeful  of  recovery,  and  makes  plans  for  the 
future  as  if  perfectly  well  (Bartholow,  Flint  and  Loomis). 

Treatment. — The  two  main  objects  of  treatment  are  the  de- 
struction of  the  parasite  and  the  removal  of  the  tuberculous  pre- 
disposition or  diathesis.  There  are  no  known  remedies  which 
will  accomplish  either  object. 

I.  Prophylactic  Treatment. — When  a  phthisical  tendency 
exists,  prophylaxis  becomes  highly  important.  It  is  possible  to 
prevent  the  development  of  phthisis.  Children  born  of  phthis- 
ical parents  should  not  be  nourished  in  infancy  by  their  own 
mothers,  but  should  be  placed  with  a  healthy  wet-nurse.  During 
childhood  they  should  be  fed  chiefly  on  good  cow's  milk,  take 
systematic  physical  exercise  in  the  open  air,  removed  from  the 
city  to  the  country.  They  should  not  lead  a  sedentaiy  life. 
They  should  not  breathe  air  laden  with  foul  vapors  or  fine  par- 
ticles of  dust.  Their  sleeping  apartments  should  be  large  and 
well  ventilated.  Sudden  changes  in  temperature  must  be 
avoided,  also  hot,  crowded  apartments.  Change  of  climate  may 
be  necessary.  All  those  agencies  which  tend  to  develop  pulmo- 
nary hyperemia  and  bronchial  catarrh  should  be  avoided. 
Flannel  should  be  worn  next  the  skin  the  whole  year.  The  diet 
should  be  simple  and  nutritious.  Cold  bathing  should  be  prac- 
ticed every  morning  to  diminish  the  snsceptibilny  to  cold.  The 
"milk-cure"  and  "grape-cure"  will  often  be  useful.  All  milk 
fed  to  children  should  be  boiled,  and  they  should  not  be  allowed 
to  come  in  contact  with  phthisical  j)arents,  except  under  guarded 
conditions. 

//.  Medicinal  Treatment. — Alcohol.  Clinical  exj^erience 
shows  that  alcohol,  in  a  certain  proportion  of  cases,  has  a  salu- 


426  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tary  effect.  If  alcoliol  produces  a  sense  of  comfort,  increases  the 
strength,  and  does  not  excite  the  circulation  or  nervous  system., 
benefit  maybe  expected  from  its  use;  and  vice-versa.  As  regards 
quantity,  some  patients  will  tolerate  a  large,  some  a  moderate, 
and  some  only  a  small  quantity.  Phthisis  is  one  of  the  diseases 
which  in  certain  cases  induce  a  remarkable  tolerance  of  alcohol. 
Some  patients  are  benefited  by  spirits,  some  by  wine,  and  some 
by  malt  liquors,  but  in  each  case  alcohol  is  the  remedial  princi- 
ple. Bartholow  says:  "Small  doses  of  alcohol  after  meals  (half 
an  ounce  for  adults)  are  highly  useful  to  promote  appetite  and 
tissue  formation.  Large  quantities  of  alcoholic  fluids  impair  the 
function  of  digestion,  and  lessen  tissue  forming." 

Cod-liver  Oil. — The  utility  of  cod-liver  oil  in  incipient 
phthisis  is  very  great.  Its  usefulness  consists  in  the  fact  that  it 
is  a  fat,  having  a  special  digestibility,  owing  to  its  containing 
bile  elements.  It  is  most  useful  in  chronic  tuberculosis  and 
fibroid  phthisis.  It  is  better  to  give  it  with  a  little  ether 
(IHxx.-oj.),  because  of  the  action  of  the  ether  in  promoting  the 
flow  of  pancreatic  fluid.  If  cod- liver  oil  be  taken  without  great 
repugnance,  if  it  do  not  impair  the  appetite  or  digestion,  or 
occasion  derangement  of  the  bowels,  it  may  be  ex23ected  to  do 
good. 

Loomis  says,  "It  has  been  claimed  that  if  cod-liver  oil  is 
commenced  very  early  it  has  the  power  of  arresting  the  phthisi- 
cal processes.  I  doubt  if  it  exerts  any  specific  influence  upon  the 
disease.  Unless  the  patient  gains  in  weight  while  using  the  oil, 
it  seldom  or  never  proves  remedial.  A  great  gain  in  weight  will 
sometimes  immediately  follow  the  administration  of  a  small 
quantity  of  oil.  It  always  acts  remeclially  with  more  certainty 
in  young  persons  and  children  than  the  aged.  In  some  instances 
diarrhoea  will  be  arrested  by  its  use  and  also  vomiting  of  food 
after  eating.  A  teaspoonf  ul  once  or  twice  a  day  is  sufficient  to 
commence  with,  the  dose  being  gradually  increased  to  a  table  - 
spoonful  three  times  a  day.  Most  patients  take  the  oil  best  im- 
mediately or  soon  after  meals."  The  pure  oil  is  better  than  the 
emulsions  and  may  be  taken  in  whiskey  or  brandy  to  disguise  its 
taste.  The  lactophosphate  of  lime,  if  well  prepared,  is  a  most 
valuable  agent  in  the  treatment  of  incipient  and  the  more  chronic 


PHTHISIS.  427 

cases  of  phthisis.  It  may  be  given  in  a  dose  of  a  tea-  to  a  des- 
sertspoonful of  the  syrup  three  times  a  day  after  meals  with  cod- 
liver  oil. 

The  hypophosphites  are  valuable  agents  to  promote  the  con- 
structive metamorphosis.  Arsenic  is  deserving  of  special  com- 
mendation, in  incipient  phthisis,  to  promote  the  appetite  and 
favor  tissue  building,  while  it  corrects  the  disordered  state  of  the 
stomach  mucous  membrane.  It  must  be  given  in  small  doses, 
two  drops  of  Fowler's  solution  three  times  daily.  The  iodide  of 
iron  and  cod-liver  oil  will  control  the  tendency  to  catarrhal 
attacks.  In  tubercular  and  fibroid  phthisis,  among  the  earliest 
symptoms  are  stomach  disorders,  poor  appetite,  atonic  or  acid 
indigestion,  and  especially  repugnance  to  fatty  elements  of  food. 
The  mineral  acids,  with  a  bitter,  such  as  tincture  of  nux  vomica, 
are  especially  serviceable.  If  there  be  acid  eructations,  pyrosis 
and  heart-burn,  the  mineral  acids,  especially  dilute  nitric  (ten  to 
fifteen  drops,  well  diluted  t.  i.  d.)  should  be  administered  before 
meals;  but  if  the  condition  be  atonic  indigestion,  the  acid  should  be 
given  after  meals.  The  nux  vomica  tincture  should  be  given 
before  meals — fifteen  drops  in  water.  Qidnine. — In  some  cases 
of  phthisis  sulphate  of  quinine  is  one  of  the  most  reliable  and 
satisfactory  antipyretics.  One  tenth  of  a  grain  of  morphine 
combined  with  the  quinine  increases  its  antipyretic  powers 
(Loomis).  Loomis  also  gives  five  grains  of  antifebrin  two  or 
three  times  in  24  hours  to  phthisical  patients  whose  temperature 
ranges  much  above  the  normal,  and  finds  that  their  appetites  are 
improved  during  its  use,  and  nervousness  lessened.  In  many 
cases,  after  the  disease  has  passed  the  first  stage,  the  fever  cannot 
be  controlled. 

Cough. — If  the  cough  is  very  distressing,  gargling  the  throat 
with  a  solution  of  bromide  of  potassium,  or  applying  a  mixture 
of  chloral  and  camphor  by  means  of  a  camel's  hair  brush  to  the 
fauces,  and  the  atomization  of  a  solution  of  cocaine  or  of  mor- 
phine, are  temporarily  beneficial.  Fothergill's  prescription  of 
hydrobromic  acid  diluted  and  spirits  of  chloroform  sometimes 
acts  well.  A  combination  of  codeine,  atropine  and  strychnine  is 
highly  efficient  as  a  remedy  for  cough,  for  night- sweats  and 
reflex  vomiting.     Picrotoxin  allays  the  vomiting:  which  accom- 


428  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

panies  the  cough  almost  as  efficiently  as  strychnine.  The  patient 
should  try  to  suppress  the  cough.  The  irritable  feeling  in  the 
fauces  may  be  allayed  by  a  bit  of  gum  arabic,  candy,  or  troche. 
The  officinal  troche  of  licorice  and  opium,  or  of  morphine  and 
ipecac,  may  be  used.  Paregoric  will  often  allay  the  cough.  The 
inhalation  of  a  few  drops  of  chloroform  will  often  control  the 
cough.  Ammonium  carbonate  in  the  infusion  of  wild  cherry 
bark  is  one  of  the  best  stimulating  expectorants,  and  it  never 
nauseates.  A  solution  of  morphine  in  glycerine  applied  to  the 
fauces  with  a  brush,  relieves  the  cough  of  phthisis.  A  better 
mixture  is  glycerine  two  parts,  whiskey  one  part  and  crystalized 
sugar  enough.  This  should  be  allowed  to  trickle  slowly  down 
the  fauces. 

Tannic  acid  (gr.  xx.  to  oiv.  of  aquas)  is  good  in  chronic 
throat  troubles.     It  may  be  used  as  a  spray. 

NiyJit- sweats  are  a  part  of  hectic.  When  quinine  does  not 
control  them,  quinine  and  opium  may  do  so.  Oxide  of  zinc  (gr. 
ij-iv.)  gallic  or  sulphuric  acids,  arseniate  of  iron  (gr.  {■  to^),  ex- 
tract of  belladonna,  or  sulphate  of  atropia  hypodermically, 
picrotoxine,  ergot,  all  may  be  tried  at  different  times.  Atropia 
is  the  most  reliable.  Sponging  the  body  with  hot  water,  or 
vinegar  and  water,  is  sometimes  effective.  Sponging  with  as- 
tringent waters  (alum  in  alcohol)  is  sometimes  efficacious. 

Diarrhoea. — If  the  diarrhoea  is  dependent  upon  catarrh, 
with  or  without  ulcerations  in  the  small  intestine,  cod-liver  oil 
and  the  hypophosphites  of  lime  and  soda  will  often  be  of  ser- 
vice. Five  grains  of  pancreatin  given  two  hours  after  eating  will 
often  relieve  the  intestinal  pain  even  in  the  later  stages  of  the 
disease.  Ten  grains  of  bismuth,  combined  with  a  twelfth  of  a 
grain  of  morphine,  after  each  movement,  will  almost  certainly 
control  the  diarrhoea.  If  the  diarrhoea  depends  upon  ulceration 
of  the  large  intestine,  all  that  can  be  done  is  to  give  temporary 
relief  by  opium  suppositories.  When  diarrhoea  is  persistent  and 
accompanied  by  rapid  emaciation,  it  is  tubercular.  For  the 
diarrhoea,  Bartholow  gives  two  drops  of  Fowler's  solution  and 
ten  drops  of  laudanum.  Vomit  rug  after  meals  is  often  a  trouble- 
some attendent  of  phthisis.  Champagne  with  the  food,  hydro- 
cyanic acid,  and  pepsin  are  useful,  but  the  most  certain  relief  is 


PHTHISIS.  429 

obtained  by  giving  the  patient  a  glass  of  hot  water  every  two 
hours,  followed  in  half  an  hour  by  a  teaspoonf ul  of  raw  scraped 
beef  made  into  a  sandwich. 

Creosote. — Bartholow  thinks  that  from  one  to  five  minims  of 
pure  beech-wood  creosote  given  three  times  daily,  has  distinct 
curative  power  in  suitable  cases  of  phthisis. 

Hcemoptysls. — The  most  valuable  remedies  for  the  arrest  of 
haemoptysis  are  rest  and  opium.  Lead,  ergot  and  ice  are  recom- 
mended. Turpentine  is  more  reliable  than  any  remedy  except 
opium.  Local  pains  in  the  chest  may  be  relieved  by  blisters, 
sinapisms,  liniments  or  the  belladonna  plaster. 

Antiseptic  Treatment  by  Inhalation.— -Bartholow  says,  "The 
value  of  antiseptics  by  the  method  of  protracted  inhalation  is 
just  being  recognized.  The  method  consists  in  charging  the  air 
of  a  suitable  apartment  with  a  volatile  remedy  which  the  patient 
can  breathe  for  a  half  to  one  hour  or  longer.  I  advise  the  inhal- 
ation by  the  protracted  method  of  ethyl  iodide,  carbolic  acid,  car- 
bolic acid  and  tincture  of  iodine,  iodol,  iodoform,  oxygen,  etc. 
The  method  of  germicide  treatment  by  rectal  injection  of  sul- 
phurretted  hydrogen,  and  carbonic  acid,  has  fallen  into  disuse  in 
this  country.  I  hope  I  may  not  be  considered  egotistic  and  pre- 
judiced when  I  say  that  this  mode  (atomization  of  solutions)  of 
using  the  remedies  is  not  good — is  not  effective. " 

Loomis  says,  "  The  antiseptic  treatment  of  phthisis  has  not 
thus  far  given  satisfactory  results.  Carbolized  inhalations  have 
been  quite  extensively  employed  with  very  favorable  results  ac- 
cording to  some  observers;  but,  after  quite  an  extensive  trial,  my 
experience  is  decidedly  against  their  use.  The  injection  of  cav- 
ities through  the  chest  walls  has  not  been  followed  by  satisfac- 
tory results.  I  have  found  the  hypodermic  use  of  antiseptics  to 
fail,  not  only  in  counteracting  the  sepsis,  but  in  reducing  the 
high  tenrperature.  I  believe  it  is  utterly  futile  to  attempt  to 
reach  the  bacilli  imbedded  in  tubercular  or  caseous  products.'1 
Again  Bartholow  says,  "Cases  of  phthisis  have  been  recently  re- 
lated as  cured  by  the  inhalation  of  highly  heated  air.  If  the  air 
is  deprived  of  its  moisture  the  temperature  at  which  it  can  be  in- 
haled ranges  from  If  0°  F.  to  300°  F.  This  method  is  based  on 
the  power  of  heat  to  inhibit  or  destroy  the   bacilli.     It  is  proba- 


430  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ble  that  this  mode  of  treatment  Trill  develop  into  a  highly  suc- 
cessful one." 

Hygienic  Treatment  of  Phthisis. — Phthisical  patients  should 
sleep  in  large  well -ventilated  and  well -lighted  rooms  with  a 
southerly  or  westerly  exposure.  Flannels  should  he  worn  next 
the  shin.  Cold  sponging  or  baths  often  act  as  tonics.  The 
patient  must  live  as  much  as  possible  in  the  open  air,  and  should 
avoid  sedentary  occupations. 

Diet. — The  diet  should  be  generous  as  regards  quantity. 
quality  and  variety.  The  articles  should  be  highly  nutritious 
and  adapted  to  the  digestive  powers.  Phthisical  j)atients  should 
drink  from  one  to  three  quarts  of  milk  each  day.  Cream,  butter 
and  sugar  should  enter  into  the  diet  as  largely  as  possible. 

Change  of  Climate. — Bartholow  says,  CiXo  change  of  climate 
can  be  beneficial,  as  a  rule,  after  cavities  have  been  formed, 
unless  of  slight  extent.  It  is  in  incipient  phthisis  that  a  change 
of  climate,  dry,  bracing  and  elevated,  really  exerts  a  curative 
influence."  Loomis  says,  "It  is  well  known  that  some  consump- 
tives thrive  best  in  a  warm,  moist  air,  others  in  a  cool,  dry  air; 
some  are  most  vigorous  in  winter,  others  in  midsummer.  Each 
case  must  be  carefully  analyzed,  before  any  definite  directions 
can  be  giyenvas  to  the  climate  best  suited  to  it.  We  know  of  no 
climate  which  is  entirely  and  absolutely  antagonistic  to  its  devel- 
opment. It  was  once  thought  that  a  warm,  dry  atmosphere 
alone  was  beneficial,  but  we  now  know  that  a  cold  climate  not 
only  does  not  hasten,  but  often  arrests  phthisical  processes.  The 
purity  of  the  air  is  the  chief  reason  that  elevated  regions  are  so 
beneficial  in  phthisis.  Organic  germs  are  more  abundant  in  the 
air  in  the  city  than  in  the  country.  Rain  and  ozone  free  the  air 
from  them,  the  latter  by  oxidation.  Rain  cleanses  the  air  of 
solid  particles  and  purifies  it  by  washing  down  ammonia  and 
carbonic  acid.  The  presence  of  ozone  in  the  air  is  presumptive 
evidence  of  its  purity.  The  air  of  high  mountains  and  plateaux 
and  along  the  shore  of  the  ocean  is  richer  in  ozone  than  that  of 
the  plains. 

The  benefit  which  phthisical  patients  derive  from  living 
near  pine  forests  has  long  been  known.  Turpentine  exhaled  from 
pine  or  hemlock  forests  converts  oxygen  into  ozone,  and  thus  the 


PHTHISIS.  431 

air  of  jDine  forests  becomes  pure.  Both  sea  and  mountain  air  are 
cooler  and  less  subject  to  frequent  variations  in  temperature  than 
the  air  of  the  plains.  The  question  arises,  will  the  patient  be 
benefited  by  sea  or  by  mountain  air  (  Patients  with  exhausted 
nervous  systems,  with  an  overtaxed  brain  from  excessive  mental 
labor,  or  an  all-absorbing  business,  and  who  still  retain  consider- 
able muscular  power  should  go  to  the  mountains;  while  those 
past  middle  life,  who  have  developed  phthisis  late,  who  are  in- 
capable of  much  muscular  activity  do  best  in  sea  air.  The 
health  resorts  of  this  country  are  those  of  Colorado,  Minnesota, 
Southern  California,  Georgia,  South  Carolina,  North  Carolina, 
the  Rocky  Mountain  regions  and  New  Mexico.  Loomis  obtained 
the  best  and  most  jDermanent  results  in  Asheville,  X.  C,  in 
New  Mexico,  and  in  the  Adirondack  region  of  New  York  state. 

FIBROID  PHTHISIS. 

In  typical  cases  the  lung  is  shrunken  in  size,  with  a  corres- 
ponding retraction  of  the  chest-wall  and  often  a  lateral  deviation 
of  the  spine.  In  the  substance  of  the  lung  there  are  firm,  dense 
bands  and  masses  or  nodules  of  fibroid  tissue,  frequently  deeply 
jnginented.  Tubercles  with  cheesy  centres  are  also  usually 
present.     This  variety  of  phthisis  is  comparatively  rare  (Flint). 

Causes. — It  is  a  disease  of  mature  life,  after  the  middle 
period,  and  is  extremely  rare  before  thirty  (Bartholow).  In  the 
majority  of  cases  the  age  of  patients  is  under  forty  years  (Flint). 
Next  to  heredity,  chronic  bronchitis  and  pleurisy  are  the  most 
influential  causes  (Bartholow). 

Symptoms. — Fibroid  phthisis  is  the  most  chronic  form  of  the 
disease;  its  early  history  is  that  of  bronchial  catarrh,  or  of  dry 
pleurisy;  and  it  is  not  until  after  months,  even  years,  that,  exten- 
sion taking  jilace  to  the  lungs,  the  progress  becomes  more  rapid. 
For  months  there  is  merely  a  dry  cough,  not  very  troublesome, 
but  persistent.  The  expectoration  is  slight,  and  is  nothing  but 
mucus.  The  appetite  is  but  little  impaired,  and  the  weight  ami 
strength  are  not  materially  reduced.  The  symptoms  increase  in 
severity  during  the  fall,  winter  and  spring  months  for  two  or 
three  years;  then  fever  comes  on  toward  evening,  the  appetite 


432  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

lessens,  digestion  becomes  poor,  the  weight  declines,  the  cough  is 
harassing  and  prevents  sleep,  the  expectoration  becomes  more 
profuse  and  entirely  purulent;  there  is  some  difficulty  of  breath- 
ing, the  pulse  is  small  and  weak,  and  finally  slight  chilliness  is 
felt  in  the  morning,  fever  in  evening,  and  sweating  occurs  during 
the  night.  When  the  bronchi  dilate,  the  expectoration  becomes 
profuse,  especially  in  the  morning — a  cupful  or  more  may  be 
brought  up  in  an  hour  or  two.  The  sjDutum  usually  contains 
tubercle  bacilli.  The  matter  expectorated  is  often  notably  fetid. 
The  fingers  often  become  clubbed  (Bartholow  and  Flint). 

Physical  Signs. — As  regards  physical  signs,  they  are  the  same 
in  all  forms  of  phthisis. 

Differential  Diagnosis. — Fibroid  phthisis  is  distinguished  from 
the  other  forms  by  its  slow  progress,  by  the  long  period  of 
bronchial  troubles  before  the  pulmonary  lesions  begin,  by  the 
merely  purulent  expectoration,  and  by  bronchial  dilatation  long 
before  the  cavities  by  excavation  form.  The  initial  period,  ter- 
minating in  a  bronchiectasis,  may  occupy  a  number  of  years;  at 
first  for  several  years,  there  is  winter  cough  only,  the  warm 
season  being  free  or  nearly  so  (Bartholow). 

Prognosis. — The  most  chronic  of  all  the  forms  of  phthisis  is 
the  fibroid.  The  course  of  this  disease  may  occupy  several 
years,  indeed,  an  ordinary  lifetime,  and  prove  fatal  at  last,  as  it 
involves  lesions  which  do  not  admit  of  recovery  (Bartholow). 

Treatment.- — Same  as  in  the  other  forms. 

ACUTE  MILIARY  TUBERCULOSIS. 

* 

Is  characterized  by  the  presence  of  miliary  tubercles  in  most 
of  the  organs  of  the  body.  The  organs  almost  constantly  affect- 
ed are  the  lungs,  the  liver,  the  spleen,  the  medulla  of  the  bones, 
the  kidneys,  thyroid  gland,  the  heart,  the  choroid  coat  of  the 
eye,  the  lyniph-glands  and  the  serous  membranes  (Flint). 

Causes. — It  is  caused  by  the  entrance  of  tubercle  bacilli 
into  the  blood  current,  and  their  transportation  to  most  parts  of 
the  body.  All  varieties  of  local  tuberculosis  may  be  followed 
by  acute  miliary  tuberculosis.     It  frequently  develops  in  persons 


TUBERCULOSIS PLEURISY.  433 

apparently  in  perfect  health.  All  tubercles  contain  bacilli 
(Flint). 

Symptoms. — Cases  of  this  disease  are  rare;  they  occur  mostly 
after  puberty  and  before  the  middle  period  of  life.  The  general 
symptoms  denote  a  febrile  disease.  The  disease  sets  in  with  a 
chill,  a  rather  rapid  rise  in  temperature  from  103°  to  107°  F.,  with 
remissions  and  a  rapid  pulse  120  to  150,  small,  soft  and  compres- 
sible. The  respirations  are  from  fifty  to  sixty  per  minute.  Cough 
is  more  or  less  prominent.  There  is  complete  anorexia  and  the 
prostration  is  great.  The  circulation  in  the  extremities  is  feeble; 
the  finger  nails  are  blue,  the  lips  and  nose  have  also  a  cyanotic 
hue,  and  the  countenance  soon  becomes  dusky.  The  tongue  be- 
comes dry;  sordes  accumulate  about  the  teeth;  food  is  rejected; 
tympanites  and  diarrhoea  supervene,  the  stools  have  a  light  yel- 
low color;  there  is  delirium  of  a  low  muttering  character  and 
stupor  comes  on  which  soon  passes  into  coma.  The  cases,  as  a 
rule,  present  a  striking  analogy  to  typhoid  (Bartholow  and 
Flint). 

Prognosis. — Is  unfavorable.  The  duration  of  the  disease  is 
from  a  few  clays  to  six  or  seven  weeks,  with  an  average  of  three 
weeks  (Loomis). 

Treatment. — The  consideration  of  the  treatment  of  acute 
miliary  tuberculosis  is  a  rather  barren  subject,  since  it  does  not 
appear  that  any  remedy  has  the  least  influence  over  the  disease. 
The  condition  of  the  patient  is  hopeless,  and  all  that  the  physi- 
cian can  do  is  to  palliate  symptoms  and  sustain  the  powers  of  life. 
This  is  one  of  the  diseases  in  relation  to  which  recovery  is  proof 
of  an  error  in  diagnosis  (Bartholow  and  Flint). 

PLEURISY. 

Called  also  pleivritris,  is  an  inflammation  of  the  pleural  mem- 
brane. It  may  run  an  acute,  sub -acute,  or  chronic  course,  and 
have  for  its  products  fibrin,  serum  and  fibrin,  serum,  fibrin  and 
pus,  or  new  connective  tissue.  It  may  he  primary  or  secondary 
to  some  other  disease  (Loomis). 


434  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Pathological  Anatomy. — Normally  the  pleural  membrane 
is  smooth,  polished  and  covered  with  a  single  layer  of  en- 
dothelial cells.  The  pleural  cavities  contain  normally  a  small 
quantity  of  serum.  The  first  noticeable  change  in  pleurisy 
or  pleuritis  is  redness  of  the  jDleura  from  active  hypersemia 
of  the  vessels.  Small  extravasations  of  blood  may  take  place 
on  account  of  the  bloocL  pressure.  The  pleura  loses  its 
glistening  appearance,  and  becomes  dull,  opaque  and  rough; 
the  endothelial  cells  are  rapidly  cast  off.  Very  soon  the  surface 
of  the  pleura  becomes  covered  with  a  fibrinous  exudation  and  it 
becomes  rough  and  shaggy  in  appearance. 

The  opposing  surfaces  of  the  pleura  may  be  agglutinated  by 
the  fibrin.  If  any  serum  exudes  it  gravitates  to  the  most  de- 
pendent portion  of  the  pleural  sac.  Those  are  examples  of  dry 
pleurisy,  in  which  a  very  plastic  exudation  is  thrown  out  on  the 
two  surfaces  over  a  small  extent  of  the  membrane,  union  taking 
place,  there  being  no  Other  effusion.  More  commonly,  the  pleu- 
risy is  of  the  sero -fibrinous  variety.  In  this  variety,  in  addition 
to  the  fibrinous  coating  of  the  pleura,  the  cavity  contains  serum, 
varying  in  quantity  from  a  few  ounces  to  several  pints.  When 
pus -cells  accumulate  in  sufficient  number,  the  exudation  becomes 
purulent  and  the  disease  is  called  suppurative  pleurisy  or 
empyema  (see  empyema).  The  red  blood  corpuscles  may  be  so 
abundant  as  to  stain  the  fluid  red;  it  is  then  called  hemorrhagic 
pleurisy.  In  from  four  to  six  days  after  the  onset  of  the  inflam- 
mation newly  formed  capillaries,  which  are  off- shoots  from  the 
pleural  capillaries,  make  their  appearance  in  the  deeper  parts  of 
the  layer  of  fibrin  and  cells  covering  the  pleura.  The  termina- 
tions of  acute  pleurisy  are  either  in  death,  in  resolution,  in 
chronic  pleurisy,  or  in  empyema.  It  will  be  noted  that  after 
the  most  favorable  termination  of  pleurisy  the  pleura  does  not 
return  to  its  normal  state,  but  is  left  with  a  new  growth  of  con- 
nective tissue  which  binds  the  pleural  surfaces  together  over  a 
greater  or  less  extent.  In  this  way  the  pleural  cavity  may 
become  entirely  obliterated  by  adhesions.  The  adhesions  are  at 
first  weak,  and  may  be  broken  by  active  exercise  or  by  acts  of 
coughing.  Chronic  pleurisy  differs  only  in  time  and  extent  from 
the  acute  form.     In  pleurisy  deformans  the  exudations  are  of 


PLEUEISY.  435 

great  thickness  and  extent,  and  by  adhesion  and  subsequent  con- 
traction, extensive  deformity  of  the  lung  may  result.  Pleurisy 
may  be  general  or  circumscribed  (Bartholow,  Flint  andLoomis). 

Causes. — Pleurisy  may  be  primary  or  secondary.  Exposure 
to  wet  and  cold  has  been  regarded  as  one  of  the  most  frequent 
causes  of  primary  pleurisy.  It  may  result  from  a  penetrating 
wound,  or  blows  upon  the  chest  wall,  or  fracture  of  the  ribs.  It 
is  common  in  early  life  up  to  the  middle  period,  but  is  uncom- 
mon in  old  age.  It  is  secondary  to  lobar  and  lobular  pneumonia, 
pulmonary  tuberculosis,  infarctions,  abscesses  and  gangrene  of 
the  luug,  bronchitis,  pericarditis,  etc.  Pleurisy  is  a  frequent 
complication  of  many  infectious  diseases,  such  as  scarlatina,  var- 
iola, pyaemia,  septicaemia,  acute  rheumatism,  Bright's  disease, 
scorbutus  and  gout.  Pus  is  usually  formed  in  the  pleurisies  of 
children  (Bartholow,  Flint  and  Loomis). 

Symptoms. — Acute  pleurisy  may  be  mild  or  severe.  There 
are  three  stages.  The  first  stage  is  the  period  from  the  attack 
to  the  time  when  effusion  takes  place.  The  second  stage  will 
extend  to  the  time  when  the  liquid  begins  to  diminish.  The 
third  stage  is  the  time  occupied  in  absorption  of  the  liquid.  The 
first  stage  rarely  extends  beyond  twenty -four  hours;  the  second 
and  third  stage  are  variable.  Acute  pleurisy  with  effusion,  the 
ordinary  form,  sets  in  as  any  other  acute  inflammation,  with 
chill,  general  malaise,  and  fever  with  pain  in  the  side.  There 
may  be  a  well -pronounced  chill,  but  more  often  chilly  sensations 
for  the  first  few  days.  The  pain  is  usually  acute,  lancinating, 
circumscribed,  and  is  increased  by  breathing,  coughing,  or  abrupt 
movements  of  the  body.  It  is  felt  at  the  side  of  the  chest,  some- 
times at  the  base  of  the  thorax,  occasionally  in  the  lumbar  and 
iliac  junction.  It  may  be  covered  with  a  finger  or  two.  It  is 
commonly  called  "stitch  in  the  side."  The  pain  may  be  diffused 
and  ill- defined.  It  may  cease  in  three  or  four  days,  or  continue. 
The  respiration  is  hurried  and  difficult.  The  fever  may  continue 
with  little  variation  for  about  eight  days.  The  temperature  in 
ordinary  cases  rarely  rises  above  100°  F.;  but  in  very  severe 
cases  it  may  reach  104°  F. 

Cough  is  usually  present,  but  is  sometimes  wanting.  It  is 
usually  suppressed  on  account  of  pain.     It  is  a  dry,  short,    tear- 


436  A    COMPENDIUM    OF    PRACTICAL     MEDICIJSTE. 

ing,  hacking  cough.  When  effusion  conies  on,  the  cough  de- 
clines. The  expectoration  is  slight  or  wanting,  and  when  pres- 
ent it  consists  only  of  a  little  frothy  mucus.  The  decubitus  of 
the  patient  is  highly  characteristic.  Before  effusion  has  taken 
place  the  patient  lies  on  the  sound  side;  but  when  the  effusion 
begins  to  compress  the  lung  the  patient  lies  on  the  diseased  side. 
If  a  considerable  amount  of  liquid  be  rapidly  effused  the  respira- 
tions are  rapid;  the  patient  suffers  from  a  painful  sense  of  tho 
want  of  air  or  dyspnoea,  and  may  be  obliged  to  maintain  the  sit- 
ting posture.  The  pulse  is  accelerated,  beating  from  90  to  120 
per  minute.  The  countenance  has  an  expression  of  weariness, 
anxiety  and  exhaustion  and  may  be  rmle  or  cyanosed.  It  is  a 
unilateral  disease — that  is,  it  affects  the  j^leura  of  one  side  only 
(Bartholow,  Flint  and  Loomis). 

Physical  Signs, — During  the  first  24  hours  of  acute  pleurisy, 
inspection  shows  restrained  movements  on  the  affected  side,  pal- 
pation, percussion,  and  mensuration  will  give  negative  results. 
On  auscultation  the  respiratory  murmur  will  be  found  feeble 
over  the  affected  side,  and  a  grazing  friction  sound  will  be 
heard.  As  the  plastic  exudation  takes  place  inspection  will  show 
.a  greater  loss  of  expansive  motion  on  the  affected  side;  pjalpation 
shows  diminished  vocal  fremitus;  percussion  gives  slight  dull- 
ness :  auscultation  shows  feeble  respiratory  murmur,  and  a  fric- 
tion murmur  will  be  heard  on  inspiration  and  expiration.  If  the 
pleurisy  is  confined  to  the  pleura  of  the  diaphragm  or  medias- 
tinum the  friction  sound  will  not  be  heard.  When  there  is  con- 
siderable effusion,  inspection  will  show  more  restricted  move- 
ments; palpation  shows  absence  of  vocal  fremitus  at  the  bottom 
of  the  pleural  cavity,  (on  the  sound  side  the  vocal  fremitus  is 
exaggerated);  on  percussion,  dullness  or  flatness  is  found  at  the 
base  of  the  chest,  and  the  finger  which  serves  as  a  pleximeter, 
feels  an  increased  sense  of  resistence.  Changing  the  position  of 
the  patient  changes  the  line  of  dullness.  The  resonance  over  the 
lung  above  the  level  of  the  liquid  is  increased,  constituting 
vesiculotympanitic  resonance.  On  auscultation  the  respiratory 
sound  will  be  absent  below  the  level  of  the  fluid,  and  feeble 
above  it.  (In  health  the  vocal  fremitus  is  greater  on  the  right 
side).     When  the  pleural  cavity  is  completely   filled   with  fluid, 


PLEURISY.  437 

inspection  will  show  an  enlargement  of  the  affected  side,  and  a 
bulging  of  the  intercostal  spaces.  On  the  sound  side  the  respir- 
atory movements  are  increased.  If  the  effusion  is  in  the  left 
pleural  cavity,  the  heart  will  be  displaced  to  the  right,  and  the 
apex-beat  may  be  noticed  under  the  right  nipple;  if  it  occupies 
the  right  pleural  cavity  the  apex-beat  will  be  carried  to  the  left, 
beyond  its  normal  position.  The  circumference  of  the  affected 
side  at  the  end  of  expiration,  will  be  one  or  two  inches  greater 
than  that  of  the  healthy  side;  but  at  the  end  of  inspiration  the 
difference  will  be  but  slight.  Palpation  shows  absent  vocal 
fremitus,  or  in  rare  cases  vocal  fremitus  may  persist  and  even  be 
increased.  Percussion  shows  flatness.  Auscultation  shows  entire 
absence  of  the  respiratory  sounds,  and  vocal  sounds  will  be  dis- 
tant and  indistinct.  At  the  upper  portion  of  the  pleural  cavity 
bronchial  respiration  and  bronchial  voice,  or  bronchophony  will 
be  heard.  As  the  fluid  is  absorbed  the  friction  murmur  returns, 
and  is  sometimes  so  loud  as  to  be  heard  by  the  patient  himself 
(Bartholow,  Flint  and  Loomis). 

Differential  Diagnosis. — Pleurisy  may  be  confounded  with 
pneumonia,  intercostal  neuralgia  and  pleurodynia.  Pleurisy 
begins  by  chilliness,  which  persists  for  several  days — pneumonia 
by  a  severe  rigor,  rarely  two;  the  pain  in  pleurisy  is  a  stitch,  a 
lancinating  pain,  which  can  be  covered  by  the  finger,  pneumonia 
by  a  sense  of  soreness  and  pain  much  more  diffused;  the  fever  in 
pleurisy  is  continuous — in  pneumonia  there  is  a  distinct  crisis  or 
lysis,  somewhere  from  the  fifth  to  eleventh  day;  the  duration  of 
pleurisy  is  indefinite — of  pneumonia  self -limited;  the  expectora- 
tion of  pleurisy  is  simply  frothy  mucus — of  pneumonia  rusty  or 
bloody;  in  pleurisy  the  vocal  fremitus  is  absent — in  pneumonia 
it  is  not  only  present  but  exaggerated;  in  pleurisy  there  is  a  fric- 
tion sound,  no  crepitant  rale,  and  the  bronchophony  is  not  so 
well  defined — in  pneumonia  there  is  no  friction  sound,  the  crepi- 
tant rale  is  present,  and  bronchophony  is  loud  and  clear;  in 
pleurisy  with  effusion  there  is  more  decided  dullness,  the  inter- 
costal spaces  are  pushed  out,  and  the  thorax  enlarged;  in  pneu- 
monia the  percussion  note  is  not  so  flat,  the  intercostal  spaces 
and  the  size  of  the  thorax  remain  normal.  Tntercostal neuralgia 
denotes  a  neuralgic  affection  of  the  intercostal  nerves.     The  term 


438  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

pleurodynia  is  applied  to  a  painful  affection  of  the  muscles  of 
the  thorax.  Both  affections  may  be  characterized  by  pain  resem- 
bling that  of  either  acute  pneumonia  or  pleurisy;  that  is,  a  lanci- 
nating pain  felt  especially  in  the  act  of  inspiration.  They  may 
be  accompanied  by  a  dry  cough  which  is  acutely  painful.  In 
cases  of  pleurodynia  there  may  be  pyrexia,  and  this  may  acci- 
dentally exist  in  cases  of  intercostal  neuralgia.  But  intercostal 
neuralgia,  as  a  rule,  is  not  accompanied  by  pyrexia,  and  has 
three  isolated  points  of  tenderness,  namely,  behind,  near  the 
dorsal  vertebra?;  laterally  in  one,  two  or  three  intercostal  sj3aces; 
and  anteriorly,  in  one  or  more  intercostal  sj)aces  near  the  sternum 
or  over  the  epigastrium.  In  pleurisy  there  are  signs  denoting 
effusion  and  a  friction  murmur.  Pain  in  pleurodynia  and  inter- 
costal neuralgia  is  more  marked,  as  a  rule,  in  movements  of  the 
body  than  in  the  respiratory  movements,  the  reverse  being  true  of 
the  pain  of  pleurisy  and  pneumonia.  Persons  affected  with 
intercostal  neuralgia  are  frequently  anaemic,  and  sometimes 
tubercular  (Bartholow  and  Flint). 

Prognosis. — The  tendency  is  to  recover. 

Treatment. — In  the  first  stage,  the  patient  should  receive  a 
full  dose  of  quinine  (gr.  xx.)  and  morphine  (gr.  ss.)  for  an  adult, 
and  the  effect  of  this  kept  up  by  five  grain  doses  of  quinine 
combined  with  gr.  £  of  morphine  every  four  hours.  Besides  the 
power  of  morphine  to  relieve  pain,  it  is  an  effective  remedy  in 
serous  inilammation.  By  relieving  pain  opium  diminishes  the 
determination  of  blood  to  the  inflamed  part;  for  pain  is  alone 
sufficient  to  occasion  an  increased  afflux  of  blood  to  a  part. 
Opium  places  the  system  in  a  condition  to  tolerate  better  the 
local  affection.  Aconite  is  a  valuable  sedative  remedy  in  the 
early  stage  of  this,  as  of  other  acute  inflammations.  It  should  be 
given  in  drop  doses  of  the  tincture  every  fifteen  minutes  for  two 
hours,  and  then  hourly.  Saline  purgatives  should  be  given. 
When  the  exudation  is  poured  out,  carbonate  of  ammonia  in  a 
solution  of  the  acetate  (gr.  v.-x.  in  Sss.)  should  be  given.  They 
should  take  the  place  of  the  quinine  and  morphine.  Saline  laxa- 
tives must  be  given,  and  once  a  day  gr.  ^  of  pilocarpine  may  be 
administered  to  keep  the  skin  active. 


PLEURISY. 


439 


Diuretics  are  sometimes  effective  in  removing  the  effusion. 
Half  an  ounce  of  the  infusion  of  digitalis,  freshly  made  from 
English  leaves,  given  three  or  four  times  a  day,  with  the  bitar- 
trate  or  acetate  of  potassium,  is  highly  effective.  The  quantity 
of  fluid  ingested  should  be  as  small  as  possible.  According  to 
Loomis,  if  the  patient  presents  the  signs  of  anaemia,  the  syrup  of 
the  iodide  of  iron  should  be  given  in  teaspoonful  doses  three  or 
four  times  each  day.  Loomis  says:  "The  remedial  agent  which 
seems  to  me  to  have  the  greatest  power  in  promoting  the  absorp- 
tion of  an  effusion  is  the  syrup  of  the  iodide  of  iron."  The  diet 
should  be  nutritious,  tonic  remedies  are  useful,  and  a  little  wine 
or  spirit  may  be  allowed. 

Going  out  of  doors  and  gentle  exercise  are  to  be  encouraged. 
Counter  irritation  may  do  good.  Cod-liver  oil  and  extract  of 
malt  may  be  given,  and  the  digestion  stimulated  by  bitters  and 
mineral  acids.  When  a  large  effusion  exists,  especially  if  puru- 
lent, it  becomes  necessary  to  remove  it  by  the  operation  of 
thoracentesis  (see  empyema).  As  death  has  occurred  several 
times  very  unexpectedly  after  the  operation  of  thoracentesis  cer- 
tain precautions  are  necessary.  When  the  effusion  is  large,  the 
whole  amount  should  not  be  withdrawn  at  once  (Bartholow, 
Flint  and  Loomis). 

PRESCRIPTIONS  FOR  PLEURISY. 

R     Morhpise  sulphatis gr.  i. 

Quinise  s'ulphatis gr.  xv.-xx. — M. 

Ft.  pulv.  no.  1. 
Sig. :     Take  at  once.     (To  abort  a  beginning  pleurisy) . 

— Bartholow. 

R     Tinct.  opii  deodorata? 5vj. 

Tinct.  aconiti  radicis oij. — M. 

Sig. :     Eight  drops  in  water  every  hour.     (In  acute   pleurisy  be- 
fore effusion).  .  —Bartholow. 

R     Tinct.  iodini  comp oiij. 

Sig.:     Divide  the  affected  surface  into  three   sections  and  paint 
one  section  every  day.     (For  chronic  pleurisy  with  effusion). 

— Bartholow. 

R     Potassii  iodidi 3iv. 

Aqua? gvj.— M. 

Sig. :     Take  one  teaspoonful  in  milk  three  times  a  day. 


440  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PNEUMONIA. 

Is  an  inflammation  of  the  pulmonary  substance  or  paren- 
chyma. Pneumonia  is  the  name  commonly  used,  but  pneu- 
monitis is  the  more  appropriate  term.  The  parenchyma  of  the 
lungs  is  composed  of  pulmonary  lobules  which  are  composed  of 
air  cells,  infundibula,  alveolar  passages  and  bronchioles.  A 
bronchus  after  it  enters  a  lobule  is  called  a  lobular  bronchus  or 
bronchiole.  It  divides  dichotoniously  once  or  twice,  and  termi- 
nates in  the  alveolar  passages,  into  which  open  the  air  cells,  air 
vesicles  or  alveoli.  The  alveolar  passages  also  divide  a  few 
times,  and  end  in  funnel  shaped  spaces  called  infundibula,  the 
walls  of  which  are  composed  of  thickly  placed  air  vesicles. 
Pneumonia  is  known  in  common  language  as  "  lung  fever," 
"winter  fever,11  etc,  (Flint). 

Varieties, — I.  -Acute  lobar  pneumonia  called  by  German 
writers  croupous  pneumonia,  by  French  writers  fibrinous  pneu- 
monitis, and  by  others  pneumonic  fever.  77.  lobular,  catarrhal 
or  broncho ^-pneumonia and  777".  Embolic  pneumonia,  suppura- 
tive pneumonia  or  abscess  of  the  lung  (Flint). 

Acute  lobar  or  croupous  or  fibrinous  pneumonia  or  pneu- 
monitis is  an  acute  general  disease  characterized  by  an  inflam- 
mation of  the  vesicular  structure  of  the  lungs,  with  an  exudation 
into  the  alveoli  which  renders  them  impermeable  to  air.  A  sin- 
gle lobe,  the  whole  of  a  lung  or  both  lungs  may  be  simultane- 
ously involved  (Loomis). 

Morbid  Anatomy. — Lobar  pneumonia  may  be  divided  into 
three  stages.  1.  A  stage  of  congestion  or  engorgement,  or 
hyperaenda.  2.  A  stage  of  consolidation  or  red  hepatization. 
3.  A  stage  of  gray  hepatization.  Another  division  is  into  the 
stage  of  congestion;  the  stage  of  exudation  (red  hepatization); 
the  stage  of  resolution  (degeneration  and  extrusion  of  the  exu- 
dation); and  the  stage  of  purulent  transformation  (gray  hepatiza- 
tion). 

Iu  the  stage  of  congestion,  there  are  an  increased  blood 
supply  and  the  pouring  out  of  an  exudation.  The  lung  does  not 
collapse  when  the  thoracic  cavity  is  opened,  has  a  reddish-brown 
appearance,  is  heavier,  floats  in  water,  but  sinks  lower  than  the 


PNEUMONIA.  4J-1 

normal  lung,  crepitates  but  little  when  pressed,  and  is  no  longer 
elastic.  On  section  a  thin,  frothy,  blood-stained  serum  exudes. 
It  may  be  tenacious. 

In  the  stage  of  exudation  or  red  hepatization,  there  is  a 
pouring  out  and  coagulation  of  the  exudation.  There  is  exuded 
into  the  alveoli  and  bronchioles  an  albuminous  or  fibrinous  fluid 
of  great  viscidity,  and  with  it  leucocytes  which  have  wandered 
from  the  vessels,  and  red- blood -corpuscles  present  by  cliapedesis, 
and  blood  by  the  rupture  of  distended  capillaries.  In  the  cap- 
illaries of  the  inflamed  area  the  blood  current  is  finally  stopped. 
The  albuminous  or  fluid  exudation  remains  fluid  for  a  short 
time,  and  then  solidifies  or  coagulates.  When  this  process  is 
completed,  the  inflamed  part  is  solid,  entirely  without  air,  and 
falls  immediately  to  the  bottom  when  jDlaced  in  a  vessel  of  water. 
The  volume  of  the  affected  lung  is  increased;  so  much  so  that  it 
often  bears  the  impress  of  the  ribs.  The  lung  is  friable,  easily 
torn  and  non -crepitant.  On  section  a  dirty  red  viscid  fluid  oozes 
from  the  surface.  The  cut  surface  has  a  reddish  color,  and  is 
granular,  resembling  liver-tissue.  This  granular  appearance  is 
due  to  the  little  masses  of  coagulated  exudation  filling  the  cavity 
of  the  alveoli.  The  granules  can  be  lifted  out  of  the  mold  in 
which  they  are  formed  by  means  of  a  fine  needle.  There  are  two 
directions  which  the  inflammatory  process  may  now  assume:  to- 
ward resolution,  or  toward  purulent  transformation.  When 
resolution  takes  place,  the  albuminous  material  which  had  solidi-. 
fied  undergoes  liquefaction,  the  watery  parts  being  absorbed  and 
the  solid  expectorated. 

When  the  purulent  transformation  takes  place,  there  is  a 
change  in  the  density  and  color  of  the  affected  lung.  The  pus- 
cells  become  numerous.  The  consistency  becomes  less  and  less 
until  the  tissue  is  a  mere  pulp,  readily  breaking  down  on  pres- 
sure. On  section  the  surface  presents  a  uniformly  dirty  gray 
appearance.  On  slight  pressure  a  reddish  gray  or  dirty  white 
pnriform  fluid  flows  from  the  cut  surface.  The  granular  look  of 
the  second  stage  has  disappeared. 

Termination. — Lobar  pneumonia  may  terminate  in:  1.  Reso- 
lution. 2.  Suppuration.  3.  Abscess.  4.  Gangrene.  5.  Chronic 
pneumonia. 


442  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Abscess  may  follow  suppuration.  These  abscesses  vary  in 
size  from  that  of  a  pea  to  one  which  may  occupy  an  entire  lobe. 
They  may  open  into  the  pleural  cavity.  Gangrene  occurs  in 
about  two  per  cent,  of  all  cases.  It  is  liable  to  occur  when  there 
is  great  constitutional  weakness,  and  in  chronic  alcoholismus  or 
in  septicaemia.  In  childhood,  except  before  the  second  year, 
croupous  pneumonia  is  rare.  Double  pneumonia  is  more  frequent 
than  in  adult  life.  In  old  age,  the  pneumonic  process  usually 
begins  in  the  upper  lobes.  Gangrene  is  far  more  frequently  a 
termination  of  lobar  pneumonia  in  old  age  than  at  any  other 
period.  It  is  a  law  of  the  disease  that  lobar  pneumonia  attacks 
the  lower  lobe  of  the  right  lung  most  frequently;  the  next  most 
frequent  seat  is  the  lower  lobe  of  the  left  lung;  then  the  upper 
lobe  of  the  right,  the  middle  lobe  of  this  lung  being  least  fre- 
quently involved.  According  to  statistics  of  Juergensen  the 
right  lung  was  affected  in  53.7  per  cent.,  the  left  lung  in  38.23 
per  cent.,  both  lungs  in  8.07  per  cent.  According  to  Bartholow, 
the  inferior  lobe  of  the  right  lung  is  the  point  of  election,  being 
the  seat  of  the  inflammation  in  three -fourths  of  the  cases.  Ac- 
cording to  the  analysis  of  121  cases  by  Dr.  Flint,  in  29  cases  it 
was  limited  to  the  lower  lobe  of  the  right,  and  in  25  cases  to  the 
lower  lobe  of  the  left  lung.  It  extended  over  the  whole  of  the 
right  lung  in  27,  and  over  the  whole  of  the  left  lung  in  nine 
cases.  It  was  limited  to  the  upper  lobe  of  the  right  lung  in 
eight,  and  to  the  upper  lobe  of  the  left  lung  in  three  cases.  It 
was  seated  in  the  lower  lobe  of  both  lungs  in  eight  cases. 

The  name  " crossed  'pneumonia'1'1  has  been  applied  to  the 
disease  when  the  lower  lobe  of  one  lung  and  the  upper  lobe  of 
the  opposite  lung  are  affected.  Double  'pneumonia  occurs  in 
from  5  to  15  per  cent,  of  cases,  and  is  more  frequent  in  senile 
than  in  the  adult  period  of  life.  According  to  Loomis  the  stage 
of  congestion  lasts  from  one  to  three  days;  red  hepatization  from 
three  to  seven  days;  and  gray  hepatization  from  two  to  thirteen 
days.  In  old  age  the  stages  merge  rapidly  into  each  other; 
abscess  of  the  lung  may  occur  within  36  or  48  hours  after  the 
onset.  Over  a  pneumonic  lung  there  is  usually  a  circumscribed 
pleurisy.  In  a  strict  sense,  nearly  every  case  of  pneumonia  is  a 
pleuro-pneumonia  (Bartholow,  Flint  and  Loomis). 


■PNEUMONIA.  443 

Causes. — Among  the  predisposing  causes  age  ranks  first. 
There  are  three  periods  in  life  in  which  the  liability  to  pneumo- 
nia is  greatest:  early  childhood;  20  to  40;  and  after  60.  From 
reliable  data  it  appears  that  lobar  pneumonia  is  five  times  more 
frequent  in  the  first  two  years  of  life  than  in  the  whole  succeed- 
ing eighteen.  Nine-tenths  of  all  deaths  after  the  sixty-fifth 
year  are  caused  by  lobar  pneumonia.  The  disease  occurs  much 
oftener  among  males  than  females.  In-door  life,  a  vitiated  at- 
mosphere, excesses,  especially  alcoholic,  and  bad  hygienic 
influences  of  every  kind  which  induce  debility  favor  attacks  of 
pneumonia.  Frequently  the  attack  is  excited  by  some  unusual 
exposure,  such  as  working  in  the  cold  and  wet  or  sleeping  out  of 
doors  at  night.  Diphtheria,  measles,  erysipelas,  small-pox,  and 
other  acute  infectious  diseases  must  be  regarded  as  predisposing 
causes.  One  attack  of  pneumonia  predisposes  to  others;  twenty- 
eight  attacks  have  been  noted  in  one  individual.  Pneumonia 
may  follow  a  severe  blow  or  injury  to  the  chest  or  shock  from 
any  traumatic  cause.  In  the  aged,  lobar  pneumonia  has  devel- 
oped as  soon  as  four  hours  after  fracture  in  the  hip  joint.  Those 
parts  of  the  year  characterized  by  humidity,  high  winds  and  lowT 
temperature  invite  the  disease.  In  this  country  it  prevails  most 
in  winter  and  spring.  Pneumonia  is  unknown  in  the  Polar 
regions.     North  and  east  winds  favor  its  development. 

Loomis  gives  the  following  facts  which  tend  to  prove  that 
lobar  pneumonia  is  not  a  local  malady:  "  Cold  does  not  influ- 
ence the  prevalence  of  pneumonia  as  it  would  were  it  a  local 
disease  (e.  g.  bronchitis).  Wet  and  cold  increase  a  bronchitis 
but  not  a  pneumonia  rate.  Lobar  pneumonia  is  more  prevalent 
in  our  Southern  than  in  our  Northern  states,  affecting  especially 
the  negro  population,  and  often  proves  the  scourge  of  cotton 
and  sugar  plantations.  The  prevalence  of  pneumonia  increases 
from  pole  to  equator.  All  acute  general  diseases  increase  with 
the  population,  pneumonia  does  this.  Statistics  show  pneumonia 
to  be  more  frequent  in  New  York  City  now  than  twenty  years 
ago.  Again,  there  is  no  relation  between  the  amount  of  lung 
involved  and  the  intensity  of  the  symptoms.  In  local  inflamma- 
tions the  reverse  of  this  is  true.  No  second  chill  occurs  when 
another  lobe  is  attacked.     The  absence  of  a  known  period  of  in- 


444  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

cubation,  of  a  typical  temperature  range,  and  of  characteristic 
surface  phenomena,  and  the  fact  that  the  disease  is  not  contagious 
are  the  reasons  advanced  by  those  who  regard  it  as  a  local,  not  a 
general  disease. 

The  resemblances  of  pneumonia  to  acute  general  diseases 
are:  distinct  chill,  an  orderly  pyrexia,  a  rather  typical  course, 
i.  e.  a  day  of  abrupt  crisis,  a  definite  duration,  and  the  symptoms 
following  in  regular  sequence.  There  is  a  peculiar  facies ;  an  oc- 
casional herpetic  eruption;  nephritis  is  not  rare;  the  cerebral 
symptoms  resemble  those  of  the  exanthemata;  there  are  sweats 
and  sudamina;  and  its  mode  of  commencement.  Coma  in  the  old 
and  convulsions  in  the  young  indicate  that  it  is  an  acute  general 
disease.  We  have  abortive  cases  of  pneumonia,  just  as  we  have 
abortive  cases  of  typhoid.  Pneumonia  is  allied  to  acute  general 
diseases  by  the  fact  that  certain  complications  occur.  It  is  some- 
times a  disease  of  intra- uterine  life.  No  local  disease  occurs  in 
the  foetus.  The  success  of  modern  methods  of  treatment  based 
on  this  belief  bears  evidence  to  its  being  a  general,  self -limiting, 
acute  febrile  disease.  Pneumonia  is  thus  admitted  to  be  a  gen- 
eral constitutional  disease  with  local  manifestations.  It  seems 
probable  that  the  real  exciting  cause  is  a  microbe  (Bartholow, 
Flint  and  Loomis). 

Symptoms. — /.  Subjective  Symptoms. — For  a  day  or  longer 
there  may  be  malaise,  anorexia,  headache,  dull  pains  in  the  limbs, 
back  and  lumbar  region,  vertigo,  epistaxis,  slight  diarrhoea  or 
jaundice,  and  flashes  of  heat  and  rigors.  In  most  cases  the  in- 
vasion is  sudden,  and  the  disease  is  ushered  in  by  a  distinct  chill. 
Generally  the  patient  is  seized  with  a  chill  in  the  night.  This 
chill  is  intense  and  prolonged,  more  so  than  in  any  other  disease 
except  pygemia  and  malarial  fever.  It  lasts  from  one-half  to 
three  hours.  Its  abruptness  and  violence  are  characteristic.  A 
distinct  chill  is  less  frequent  in  the  pneumonia  of  old  age;  yet 
when  an  old  person  has  a  marked  chill  pneumonia  may  always 
be  suspected.  The  initial  chill  is  rarely  repeated.  A  child  may 
awake,  in  the  night  with  a  burning  skin,  bounding  pulse,  flushed 
face  and  hacking  cough  as  the  first  symptoms.  With  the  initial 
symptoms  there  are  rise  in  temperature,  pain  in  side,  accelerated 
breathing,  dyspnoea,  cough,  expectoration,  flushed  and  anxious 


pxeuxoxia.  445 

countenance,  headache,  loss  of  appetite,  intense  thirst,  scanty 
urine,  and  heavily- coated  tongue.  The  symptoms  increase  until 
the  day  of  crisis,  when  they  either  suddenly  remit  and  the  patient 
breaks  out  in  a  profuse  sweat,  or  they  subside  by  lysis.  The 
defervescence  is  usually  reached  between  the  fifth  and  ninth  day. 
II.  Objective  Symptoms. — 1.  Respiration  is  more  con- 
stantly increased  in  frequency  in  pneumonia  than  in  any  other 
acute  disease,  and  varies  from  30  to  80  per  minute.  The  respira- 
tions may  be  80  per  minute  and  the  pulse  rate  not  more  than  100. 
The  acceleration  is  not  in  proportion  to  the  amount  of  lung  in- 
volved. It  is  panting,  not  catching  in  character.  It  may  or  may 
not  be  accompanied  by  dyspnoea.  Expansion  of  the  nostrils  is  an 
early  symptom  in  the  pneumonia  of  children. 

2.  Dyspnoea  is  by  no  means  constant.  It  does  not  depend 
ivpon  the  amount  of  lung  involved.  It  is  often  so  great  that  the 
patient  is  unable  to  lie  down.  The  greatest  dyspnoea  occurs 
where  there  is  marked  nervous  prostration,  and  in  complicated 
pneumonia.  In  children  dyspnoea  is  most  marked  when  the  apex 
of  the  lung  is  involved. 

3.  Pain  follows  the  chill.  It  is  situated  under  the  nipple 
of  the  affected  side.  It  is  sharp  and  stabbing,  often  located  over 
the  pneumonic  spot,  and  is  intensified  by  coughing,  sneezing, 
and  deep  inspirations.  It  is  the  pleurisy  that  causes  the  pain. 
Pneumonia  itself  is  a  painless  disease.  Pain  in  the  affected  side 
rarely  continues  beyond  the  third  or  fourth  day.  If  it  continue 
beyond  the  eighth  day  it  is  evidence  of  pleuro-pneumonia.  It  is 
present  in  85  per  cent,  of  all  cases.  In  old  age  pain  is  never 
severe. 

4.  Cough  is  present  in  over  90  per  cent,  of  the  cases.  It 
comes  on  within  24  hours  after  the  advent  of  the  disease.  At 
first  it  is  short  and  " hacking"  in  character.  Old  people  with 
pneumonia  often  have  no  cough. 

5.  Expectoration  is  characteristic.  In  the  first  48  hours  of 
the  disease  it  is  simply  frothy  mucus.  Then  it  becomes  semi- 
transparent,  viscid,  gelatinous  and  tenacious,  but  never  opaque. 
So  tenacious  is  it  that  the  cup  containing  it  maybe  inverted 
without  spilling  the  mass.  This  tenacity  in  great  part  causes 
the    difficulty   of    expectoration.     Its    color   varies.     About  the 


446  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

second  day  the  "brick  -dust"  or  "rusty"  sputa  may  be  observed. 
This  color  is  due  to  the  presence  of  blood.  The  sputa  may  be 
creamy  and  yellow,  or  of  a  very  dark  or  prune  juice  color;  the 
latter  occurs  especially  in  alcoholic  subjects.  Greenish  sputa 
may  occur  in  the  middle  of  the  disease  and  during  resolution. 
When  resolution  occurs  the  sputum  becomes  abundant,  and  of  a 
yellow  creamy  color.  There  may  be  no  sputum  throughout;  or 
it  may  not  appear  until  the  sixth  or  even  the  twelfth  day.  The 
sputum  may  remain  brick  dust  till  the  ninth  or  tenth  clay.  In 
children  sputa  are  usually  absent.  In  senile  pneumonia  expecto- 
ration is  never  an  early  symptom.  The  sputa  are  rusty  in  about 
33  per  cent,  only  of  such  cases;  frothy  or  catarrhal  sputa  are  the 
rule.  A  chocolate -looking  serous  sputum,  appearing  soon  after 
the  onset  of  pneumonia,  shows  a  depraved  condition  and  indi- 
cates "typhoid  pneumonia." 

6.  Temperature-range  of  a  typical  case  of  lobar  pneu- 
monia indicates  that  it  belongs  to  a  remittent  or  sub -remittent 
type.  The  temperature  rises  suddenly  during  the  initial  chill, 
and  in  two  or  three  hours  after  it  may  range  from  102°  to  105°  F. 
After  the  first  twenty-four  hours  the  temperature  is  subject  to 
morning  and  evening  exacerbations  and  remissions.  It  is  usually 
highest  on  the  evening  of  the  third  day.  A  sudden  rise  of  tem- 
perature may  indicate  a  complication.  The  sudden  fall  of  tem- 
perature on  the  fifth  or  sixth  day  indicates  a  crisis,  and  the 
beginning  of  convalescence.  The  fever  may  reach  its  highest 
point  just  before  the,  crisis.  Pneumonia  is  one  of  the  few  diseases 
terminating  by  crisis.  When  the  temperature  declines  gradually 
("lysis"),  a  normal  point  is  usually  reached  by  the  ninth  day, 
sometimes  not  until  the  twelfth  or  fourteenth.  A  continuously 
high  temperature  after  the  tenth  clay  indicates  purulent  infiltra- 
tion. Pneumonia  at  the  apex  has  the  highest  temperature  range. 
The  fifth  and  seventh  are  the  days  of  crisis  in  the  majority  of 
uncomplicated  cases.  Of  867  cases,  677  ended  before  the  eighth 
day. 

7,  Pulse  varies  with  the  severity,  extent  and  stage  of  the 
pneumonia.  In  mild  cases  it  ranges  from  90  to  120;  if  it  con- 
tinue above  120  the  case  is  severe.  The  pulse  is  soft  and  full  at 
the  onset.     Later  it  becomes  small  and  feeble.  It  is  not  the  most 


PNEUMONIA.  447 

extensive  pneumonia  that  is  accompanied  by  the  greatest  flag- 
ging of  the  heart.  Heart  failure  may  exist  before,  or  just  as 
hepatization  is  commencing.  When  the  heart  is  failing  the  pulse 
shows  that  the  artery  is  unequally  filled  by  each  beat.  In  chil- 
dren the  pulse  rate  may  be  200  per  minute. 

8.  The  skin  is  often  hot  and  dry  until  the  crisis,  but  it  may 
be  bathed  in  perspiration  from  the  onset.  When  the  parched  skin 
becomes  moist  at  the  acme  of  the  disease  and  the  patient  is  not 
relieved,  it  is  an  unfavorable  symptom. 

9.  Countenance. — In  most  cases  the  expression  of  the  coun- 
tenance is  characteristic.  The  face  is  anxious,  and  over  the  malar 
bones  is  a  mahogany  flush,  not  diffused  as  in  typhus  fever,  but 
well  defined  and  circumscribed.  It  is  called  the  "pneumonic 
spot."  The  rest  of  the  face  is  pale.  Usually  one  cheek  is  more 
flushed  than  the  other;  this  is  due  to  disturbance  of  the  vaso- 
motor system.  The  lips  may  be  cyanosed,  but  at  the  crisis  they 
become  pale. 

10.  Herpetic  eruption  upon  the  cheeks,  nose,  lips  or  eyelids 
occurs  in  about  fifty  per  cent,  of  cases.  It  is  rare  before  the  sec- 
ond or  third  day  and  may  not  occur  until  the  crisis. 

Sudamina  may  accompany  profuse  sweating.  In  children 
wmile  the  surface  of  the  body  is  hot  and  dry,  the  extremities  are 
cool  and  the  pneumonic  flush  is  bluish.  Cyanosis  of  the  extrem- 
ities is  more  frequent  than  in  adults,  and  herpes  labialis  is  more 
constant.  In  old  age  the  pneumonic  flush  is  often  the  first  ob- 
jective sign  of  pneumonia.  The  eye-lids  alone  are  cyanotic.  The 
face  assumes  a  sallow  hue  and  the  surface  heat  is  succeeded  by  a 
cold,  clammy  perspiration. 

11.  Cerebral  symptoms  are  headache,  slight  delirium  at 
night  (it  may  be  active),  coma  and  convulsions  in  children. 

12.  Digestive  symptoms  may  be  nausea  and  vomiting,, 
anorexia  and  thirst.  The  tongue  and  lips  may  become  brown, 
dry  and  cracked,  and  sordes  collect  on  the  teeth.  The  urine  in 
pneumonia  is  scanty  and  high  colored.  Epistaxis  is  most  fre- 
quent at  the  onset  and  at  the  crisis.  Swelling  of  the  veins  of  the 
hands  in  children  is  an  unfavorable  symptom.  When  pneumonia 
is  to  terminate  fatally,  dyspnoea  increases,  the  patient  "sinks,11 
the  pulse  becomes  small,  rapid  and  intermittent,  moist  rales  are 


448  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

heard  in  the  bronchi,  the  face  is  livid  and  the  body  is  bathed  in  a 
profuse  cold,  clammy  sweat. 

Abscess. — Acute  pneumonia  terminates  in  abscess  in  two  per 
cent,  of  all  cases.  In  these  cases,  the  sputa  are  copious  and  fetid, 
yellowish  in  color,  and  consisting  almost  wholly  of  pus.  The 
fever  is  of  the  hectic  type,  and  is  accompanied  by  rigors  and 
sweats.  Gangrene,  as  a  termination  of  pneumonia,  has  been  found 
in  about  14  per  cent,  of  cases.  In  these  cases  there  is  sudden 
collapse,  rapid,  feeble,  intermittent  pulse,  face  pale  and  death- 
like, and  profuse  expectoration  of  blackish -green  masses.  The 
breath  is  offensive  and  the  body  has  a  cadaverous  smell.  The 
sickening  odor  of  pulmonary  gangrene  is  most  perceptible  after 
coughing.     Gangrene  has  its  seat  in  the  lower  lobes  of  the  lung. 

Purulent  infiltration  may  be  suspected  when  resolution 
does  not  take  place  at  the  period  of  crisis  and  the  temperature 
remains  high,  accompanied  by  symptoms  of  prostration  and 
profuse  purulent  expectoration.     Death  results  from  exhaustion. 

Typlioid  pneumonia  is  a  term  that  has  been  applied  to  a 
pneumonia  attended  by  typhoid  symptoms.  There  is  no  sputa, 
no  dyspnoea,  no  pain,  no  cough.  Sordes  collect  on  the  teeth  and 
s;ums.  The  tongue  is  thickly  coated,  and  later  covered  with 
thick  black  crusts.  There  is  stupor,  somnolence  and  continual 
low,  muttering  delirium.  This  form  is  common  in  the  aged. 
Bilious,  or  gastric  pneumonia,  is  lobar  pneumonia  occurring  in 
malarial  districts,  accompanied  by  gastro- enteritis  with  hej^atic 
symptoms. 

Physical  Signs. — I.  First  Stage,  or  Stage  of  Congestion. — 
Inspection  shows  diminished  respiratory  movements  on  the  af- 
fected side.  Palpation  shows  increased  vocal  fremitus  over  the 
affected  lung.  Percussion  shows  slight  dullness.  Auscultation 
shows  a  feeble  vesicular  murmur.  There  is  broncho-vesicular 
breathing.  Within  24  to  36  hours  there  is  heard  with  or  at  the 
end  of  inspiration  a  fine  crackling  sound  over  the  inilamed  region 
— the  crepitant  rale.  This  rale  is  highly  diagnostic  of  pneumo- 
nia. .  It  has  been  compared  to  the  sound  produced  by  rubbing  a 
lock  of  hair  between  the  fingers  in  front  of  the  ear,  and  to  the 
burning  of  grains  of  salt  on  live  coals.  As  the  sound  is  produced 
by  the  separation  of  the  bronchioles  and  alveoli,  adherent  by  the 


PNEUMONIA.  449 

viscidity  of  the  albuminous  exudation,  it  is  obvious  that  it  can 
occur  only  during  inspiration.  When  consolidation  takes  place, 
the  crepitant  rale  ceases. 

II.  Second,  or  Stage  of  Heal  Hepatization. — Inspection 
shows  lost  respiratory  movements  of  the  affected  side,  and  in- 
creased on  the  sound  side.  Palpation  shows  increased  vocal 
fremitus.  Percussion  gives  complete  dullness.  Auscultation 
gives  bronchial  respiration  and  bronchojihony  is  heard  over  the 
whole  of  the  consolidated  lung.  If  the  pleural  cavity  be  partly 
filled  with  fluid,  the  voice  sounds  may  be  segophonic  at  the  level 
of  the  fluid.  Pectoriloquy  may  be  heard  (i.  e.,  when  the  voice 
sounds  directly  into  the  ear  from  the  chest). 

777".  Third,  or  Stage  of  Gray  Hepatization. — Inspection 
shows  returning  respiratory  movements.  Palpation  shows  vocal 
fremitus  gradually  diminishing.  Percussion  shows  diminishing 
dullness.  Auscultation  shows  broncho-vesicular  breathing,  and 
rale  redux  (i.  e.,  resolving  subcrepitant  rale). 

Differential  Diagnosis. — -Pneumonia  may  be  confounded  with 
pulmonary  congestion  and  oedema,  cajrillary  bronchitis,  pleurisy, 
hypostatic  congestion,  catarrhal  pneumonia,  pulmonary  infarc- 
tion, meningitis  and  typhoid  fever. 

Pneumonia  commences  with  a  chill,  followed  by  a  rapid  rise 
in  temperature  and  pain  in  the  side.  There  is  no  chill,  no  fever, 
and  no  pain  in  pulmonary  congestion  and  oedema.  The  expec- 
toration of  pneumonia  is  viscid  and  rutsy;  in  pulmonary  congest- 
ion and  oedema,  it  is  profuse,  watery  and  blood-stained.  As  a 
rule,  pneumonia  is  unilateral;  pulmonary  (edema  is  bilateral. 
In  capillary  bronchitis  there  is  heard  all  over  the  chest  the  sub- 
crepitant rale,  the  expectoration  is  muco-purulent,  the  tempera- 
ture range  is  low,  there  is  no  dullness  on  percussion,  no  bronchial 
breathing,  and  cyanosis  is  marked.  The  breathing  is  labored  in 
bronchitis,  and  panting  in  pneumonia.  Acute  pleurisy  begins 
with  chilliness,  or  several  rigors,  and  low  temperature;  pneu- 
monia with  a  distinct  chill  followed  by  fever.  In  pleurisy  the 
face  is  pale  and  anxious,  and  the  pulse  is  firm,  small,  tense,  and 
wiry;  in  pneumonia  the  face  has  a  mahogany  flush,  and  the  pulse 
is  full  and  compressible.  The  breathing  in  pleurisy  is  catching; 
in  pneumonia  it  is  panting.     In  pleurisy  there  is  a  dry,  hacking 


450  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

cough  with  mucous  expectoration;  in  pneumonia  rusty  sputum. 
In  pleurisy  with  effusion,  vocal  fremitus  is  diminished,  there  is 
flatness  on  percussion,  the  respiratory  sounds  are  feeble,  and 
there  is  friction  sound;  in  pneumonia  vocal  fremitus  is  increased, 
dullness  on  percussion,  crepitant  rales  and  bronchial  breathing  is 
present.  In  hypostatic  congestion,  the  expectoration  is  copious, 
watery  and  blood-stained.  It  disappears  when  the  patient  sits  up. 
Catarrhal  or  lobular  pneumonia  in  children  is  usually  secondary 
to  bronchitis,  is  developed  in  both  lungs,  has  no  days  of  crisis, 
and  no  chill.  Pulmonary  infarction  is  rare  without  cardiac 
disease  or  pyaemia,  is  non  febrile,  and  has  intense  dyspnoea.  The 
expectoration  is  small  black  clots.  Cases  of  pneumonia  with 
cerebral  symptoms  may  be  mistaken  for  meningitis,  but  this  can 
only  happen  should  the  chest  not  be  examined.  In  meningitis 
there  are  no  thoracic  symptoms,  no  dyspnoea,  and  the  face  is  pale 
and  anxious.  Pneumonia  with  typhoid  symptoms  is  sometimes 
mistaken  for  typhoid  fever.  But  the  pneumonia  which  compli- 
cates typhoid  fever  does  not  come  on  until  late  in  the  fever,  and 
the  regular  history  of  typhoid  fever  precedes  its  development 
(Bartholow  and  Loomis). 

Prognosis. — About  twenty  per  cent,  of  cases  of  pneumonia  die. 
The  prognosis  depends  on  the  age  of  the  patient.  After  sixty 
the  prognosis  is  always  unfavorable.  Most  "sudden  deaths"  in 
the  old  are  from  acute  lobar  pneumonia.  Double  pneumonia  is 
rarely  recovered  from.  Conrplications  such  as  pleurisy,  capillary 
bronchitis,  and  pericarditis  render  the  jDrognosis  unfavorable. 
The  symptoms  which  are  unfavorable  are  as  follows:  frequency 
and  feebleness  of  the  pulse;  great  frequency  and  labor  of  respira- 
tion; lividity  of  the  prolabia  and  face;  an  abundant  purulent 
or  muco-purulent  expectoration;  prune- juice  expectoration; 
active  violent  delirium;  low  muttering  delirium  with  prostration 
and  subsultus  tendinum.  The  occurrence  of  purulent  infiltra- 
tion, abscess,  or  gangrene  renders  the  prognosis  unfavorable 
(Bartholow  and  Loomis). 

Treatment. — Acute  lobar  pneumonia  is  a  well  defined,  self- 
limited  disease.  It  is  thought  to  be  a  constitutional  disease  with 
a  local  lesion.  Loomis  says  "  The  pneumonic  lung  no  more  re- 
quires treatment  than  the  intestinal  ulcers  of  typhoid  fever.  It  is 


PNEUMONIA.  451 

♦ 

the  general  condition  of  the  patient  not  the  local  changes,  which 
is  to  govern  ns  in  the  management  of  each  case."  If  a  patient  be 
seen  during  the  stage  of  congestion,  Bartholow  would  apply  five 
to  ten  full-sized  leeches.  Flint  states  that  full  doses  of  quinia, 
that  is  from  20  to  40  grains,  given  either  at  once  or  within  eight 
or  ten  hours,  may  arrest  the  disease.  Aconite  is  an  effective  sed- 
ative. Two  to  five  drops  of  the  tincture  of  aconite  root  may  be 
given  every  two  hours  in  the  first  stage.  A  large  mustard  'poul- 
tice should  be  put  on  the  chest,  and  removed  when  the  skin  is 
reddened,  to  obtain  its  stimulant  effect  on  the  vaso- motor  nerves 
within,  and  the  feet  should  be  immersed  in  a  hot  mustard  foot- 
bath. Bartholow  states  that  modern  researches  have  shown  that 
calomel  has  a  sedative  action  on  the  liver;  lessens  bile  production 
and  probably  the  whole  functional  activity  of  the  liver;  and  as  all 
cases  of  pneumonia  are  accompanied  by  hepatic  disorders,  it  is 
clear  that  calomel  is  indicated.  Calomel  acts  as  an  antipyretic  and 
should  be  given  on  the  first,  second  and  third  days  of  the  disease 
in  doses  of  from  three  to  five  grains.  When  the  exudation 
begins  to  coagulate  a  solution  of  the  carbonate  of  ammonia  (gr. 
v.-x.)  in  liquor  ammonii  acetatis  (5ss)  every  three  or  four  hours 
is  very  useful.  The  Germans  prefer  the  muriate  in  the  same 
doses.  The  chest  may  be  surrounded  with  cotton -batting  or 
flannel  jacket.  Absolute  rest  is  essential.  The  sick  room  should 
be  well  ventilated,  and  its  temperature  between  65°  and  70°  F. 
The  diet  should  consist  of  milk,  eggs,  beef-tea,  and  concentrated 
broths.  For  the  first  four  days  Loomis  would  kee]3  the  patient 
under  the  full  influence  of  opium  by  hypodermic  injections  of 
morphine.  There  are  two  sources  of  danger — heart  failure  and 
high  temperature.  Alcohol  is  the  most  efficient  means  for  pre- 
venting heart  failure.  It  is  best  to  begin  with  small  doses,  when 
the  pulse  is  frequent,  feeble  and  irregular,  and  not  more  than 
six  or  eight  ounces  of  brandy  should  be  given  in  twenty-four 
hours.  A  dicrotic  pulse,  delirium,  muscular  tremor  and  collapse 
are  indications  for  alcohol. 

To  reduce  the  temperature  there  are  two  plans  of  treatment: 
the  application  of  cold  and  internal  antipyretics.  Cold  s]X)ngmg 
may  be  practised  when  it  is  grateful  to  the  patient.  Of  the 
antipyretics,  antipyrin  and  antifebrin  are  employed.     Antifebrin 


452  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  to  be  preferred.  In  some  cases  of  pneumonia  quinine  is  more 
efficacious  than  antif  ebrin  in  reducing  fever,  given  in  doses  of  gr. 
x-xx.  every  two  hours.  If  there  is  restlessness  or  wakefulness  in 
the  third  stage,  chloral  hydrate  serves  a  most  useful  purpose. 
Fifteen  grains  at  night  is  usually  all  that  is  required.  To  jDro- 
mote  the  expectoration  and  to  relieve  the  cough  the  proper  reme- 
dies should  be  given.  In  weak  subjects  a  little  wine  may  be 
given  from  the  beginning  (Bartholow  and  Loomis). 

PRESCRIPTIONS  FOR  PNEUMONIA. 

|i     Potassii  iodidi 3j. 

Amrnonii  muriatis jiss. 

Mist  glyc}a'rhizae  co 3yj. — M. 

Sig. :     A  tablespoonful  four  times  a  day,  to   promote    absorption 
together  with  blisters  to  the  chest.  — DaCosta. 

|fc     Pulv,  digitalis gr.  vj. 

Quinias    sulphatis gr.  xij. 

Ext.  opii  

Ext.  ipecacuanha? aa.... gr.  iij. — M. 

Ft.  massa  et  in  pil.  no.  xii.  div. 
Sig. :     One  pill  three  times  a  day  with  the  preceding  mixture. 

— DaCosta. 

J&     Amrnonii  carbonatis gr.  xl. 

Infusi  serpentarise. .. §iv. — M. 

Sig. :     A  teaspoonful  every  three  hours.     (As  a  stimulant  about 
the  crisis).  — Bartholow. 

Jfc     Tinct.  veratri   viridis ITTxl. 

Spts.  setheris  nitrosi gvj. 

Liq.  potassii  citratis givss. 

Syr.  zingiberis ad §vj. — M. 

Sig. :     A  tablespoonful  every  three  hours.     (In  early  stage.) 

— DaCosta. 

JJr     Pulv.  sinapis §ss. 

Pulv.  seminis  lini oviij. — M. 

Ft.  cataplasma. 
Sig. :     Apply  to  the  chest  covering  with  oiled  silk. 

— J.  Lewis  Smith. 
Lobular  Pneumonia. — Called  also  catarrhal  or  broncho-pneu- 
monia is  always  secondary,  being  preceded  by  innammation  and 
obstruction  of  the  smaller  bronchi,  which  lead  to  the  consolidat- 
ed lobules  (Loomis). 


pxeumoxia.  453 

Causes. — It  may  be  excited  by  an  extension  downward  of 
a  catarrhal  process  from  the  tubes  to  the  air  cells.  It  is  most 
frequent  between  the  ages  of  one  and  three,  and  in  old  age.  The 
bronchitis  of  measles,  whooping  cough,  influenza,  etc.,  often 
leads  to  lobular  pneumonia.  Bad  hygienic  influences  as  to  dress, 
habitations,  humidity  and  exposure,  favor  its  development  (Bar- 
tholow  and  Looinis). 

Symptoms. — The  beginning  symptoms  are  chilliness,  followed 
by  fever,  soreness  of  the  chest  beneath  the  sternum,  cough,  ex- 
pectoration of  a  frothy  mucus  and  some  difficulty  of  breathing. 
Soon  the  breathing  becomes  rapid,  superficial  and  labored,  and 
the  alse  of  the  nose  work  quickly  and  continuously.  The  face  at 
first  is  flushed  and  rather  animated,  and  the  eyes  have  a  glaring 
expression,  but  the  lips  soon  become  bluish  and  cyanosis  spreads 
over  the  face.  The  cough,  wmich  during  the  preceding  bron- 
chitis was  loose,  loud  and  bronchial,  now  becomes  dry,  hacking, 
and  is  usually  very  painful.  The  pulse  ranges  from  140  to  200 
per  minute.  The  temperature  will  gradually  rise  to  104°- 105°  F., 
unlike  the  sudden  rise  of  lobar  pneumonia.  As  the  dyspnoea  in- 
creases, there  is  increasing  restlessness,  never  a  moment  of  quiet, 
the  struggle  for  breath  and  search  for  an  easier  position  being 
incessant.  The  respirations  are  panting  and  may  be  100  per 
minute.  As  the  struggle  for  breath  continues,  the  superficial 
veins  grow  into  thick  black  cords,  the  result  of  carbonic  acid 
poisoning,  and  the  patient,  a  child,  may  tear  the  skin  about  the 
neck  and  face  with  its  nails  in  a  vain  effort  to  remove  supposed 
obstructions.  The  tongue  becomes  dry;  sordes  collect  on  the 
gums  and  teeth,  and  aphthous  stomatitis  is  common  (Bartholow 
and  Loomis). 

Physical  Signs. — Inspection  shows  a  deep  depression  of  the 
abdomen  from  retraction  of  the  lower  ribs  on  inspiration.  Pal- 
pation shows  increase  of  vocal  fremitus  when  a  considerable 
number  of  lobules  have  collapsed.  Percussion  shows  no  change 
until  the  atelectasis  occurs,  and  then  slight  dullness.  Ausculta- 
tion shows  abundant  rales  all  over  the  chest.  They  consist  of 
subcrepitant  rales  which  are  somewhat  coarser  and  louder  than 
the  crepitant,  and  are  audible  with  both  inspiration  and  expira- 
tion.    There  are  also  mucous  and  sub- mucous  rales  produced  in 


454  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

the  larger  tubes.     There  may  be  bronchophony  (Bartholow  and 
Loomis). 

Differential  Diagnosis. — Catarrhal  or  lobular  pneumonia  may 
be  mistaken  for  croupous  pneumonia,  bronchitis,  acute  tubercu- 
losis and  oedema  of  the  lungs.  Croupous  pneumonia  is,  as  a 
rule,  unilateral  and  limited  to  a  certain  area;  catarrhal  pneu- 
monia is  bilateral  and  diffused  over  both  lungs.  The  one  is  a 
self -limited  disease,  the  other  has  no  fixed  duration.  Capillary 
bronchitis  may  be  primary;  lobular  pneumonia  is  always  second- 
ary. The  breathing  is  labored  in  capillary  bronchitis  and  pant- 
ing in  pneumonia.  The  one  gives  resonance  on  percussion,  the 
other  dullness.  In  acute  tuberculosis  the  fever  is  higher  than  in 
pneumonia.  Acute  tuberculosis  occurs  in  early  adult  life.  Lob- 
ular pneumonia  occurs  oftenest  in  the  child  of  one  to  four  years. 
In  oedema  of  the  lungs  there  is  no  fever  (Bartholow  and  Loomis). 

Prognosis. — Half  the  cases  die.  The  average  duration  of 
acute  lobular  pneumonia  is  from  ten  to  fourteen  days  (Bar- 
tholow and  Loomis). 

Treatment. — To  promote  the  expectoration  Bartholow  would 
give  three  to  six  grains  of  the  carbonate  of  ammonia  and  four  to 
eight  grains  of  the  iodide  of  ammonia  in  solution  every  two 
hours.  Some  authorities  would  give  the  muriate  of  ammonia. 
Oil  of  turpentine,  eucalyptol  and  copaiba  may  be  used  for  the 
same  purpose.  If  there  is  excessive  dyspnoea  Bartholow  would 
give  two  to  three  grains  of  the  subsulphate  of  mercury  to  produce 
vomiting,  and  thus  dislodge  the  muco-pus.  For  the  high  fever 
the  same  author  would  give  two  drops  of  tincture  of  aconite  root, 
and  one  of  tincture  of  belladonna,  every  two  hours  to  a  child  of 
two  years.  For  the  continued  high  temperature  three  grains  of 
quinine  and  one-fourth  of  a  grain  of  digitalis  can  be  given  morn- 
ing, noon  and  evening  to  a  child  of  two  years.  The  patient 
should  be  kept  in  a  warm  room  well  ventilated.  The  air  of  the 
room  may  be  filled  with  the  vapor  of  oils  of  eucalyptus  and  tur- 
pentine, by  heating  them  with  water.  The  chest  should  be 
enveloped  in  linseed  or  mild  mustard  poultices,  or  in  very  young 
children  a  stimulating  liniment  may  be  rubbed  on  the  chest  two 
or  three  times  a  day  and  cotton  -batting  applied.  The  food 
should  be  fluid  and  nutritious.     Stimulants  must  be  given  from 


PRIAPISM.  455 

the  onset  of  the  disease.  Brandy  or  gin  in  milk,  ten  to  twenty 
drops  every  three  or  four  hours,  may  be  given  to  a  very  young 
infant.  If  the  disease  is  prolonged  and  emaciation  is  marked, 
cod -liver  oil  and  the  syrup  of  the  iodide  of  iron  should  be  given, 
with  a  change  of  air  (Bartholowand  Loomis). 

PRIAPISM. 

Is  more  or  less  continuous  erection  without  desire.  Inter- 
course with  ejaculation  may  take  place  in  some  forms  of  priapism 
(Keyes). 

Causes. — Erection  has  long  been  observed  to  follow  injuries 
to  the  cerebellum  and  spinal  cord.  Out  of  eleven  cases  of  cere- 
bellar hemorrhage,  erection  of  the  penis  was  noted  six  times  by 
Serres.  Death  by  hanging  is  often  accompanied  by  partial  erec- 
tion. Erections  are  often  absent  after  some  diseases  and  injuries 
of  the  spine  producing  paraplegia;  but  in  other  cases  the  disease 
or  injury  is  attended  by  priapism.  Lallemand  mentions  the  case 
of  an  officer  who  was  thrown  from  his  horse,  and  at  once  became 
paraplegic,  and  had  priapism.  As  his  paraplegia  gradually  got 
well  his  priapism  ceased.  The  same  author  states  the  case  of  a 
soldier,  who  climbing  out  of  garrison  to  see  his  mistress,  fell 
upon  his  sacrum,  and  became  partially  paraplegic  with  priapism. 
As  the  priapism  produced  retention  of  urine,  he  attempted  to  free 
himself  of  it  by  masturbation,  but  without  success.  On  one 
occasion,  he  indulged  in  copulation  with  his  mistress  almost  con- 
tinously  for  several  hours,  until  he  had  exhausted  his  partner — 
but  all  to  no  effect.     He  had  no  pleasure  or  ejaculation. 

Large  doses  of  cantharides  will  produce  erection  without 
desire.  Prolonged  mental  exertion,  over-anxiety,  etc.,  are  some- 
times attended  by  priapism,  due  perhaps  to  some  local  injury, 
as  gonorrhoea,  the  passage  of  a  stone  or  a  sound.  Some  prostatic 
affections  are  atteuded  by  priapism.  Many  writers  mention 
leucocythcemia  as  a  cause  of  persistent  priapism.  Salzer  gives  as 
causes  extravasation  of  blood  in  the  corpora  cavernosa,  impeded 
circulation  in  the  smaller  vessels  and  the  formation  of  thrombi. 
Mackie  notes  a  case  of  persistent  priapism  lasting  twenty- one 
days  in  an  old  man  of  seventy.     After  nineteen  days  the  right 


456  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

corpus  cavernosum  swelled  and  was  relieved  by  incising  it.  He 
thinks  that  a  small  extravasation  in  the  corpus  cavernosum  was 
the  immediate  cause  of  the  priapism.  Priapism  in  children  is 
often  due  to  stone  in  the  bladder,  tight  prepuce,  worms  in  the 
rectum,  etc.  (Keyes). 

Treatment. — Is  hygienic  and  symptomatic.  The  lower  part 
of  the  spine  and  perinseum  may  be  blistered.  Electricity,  strych- 
nine, ergot  and  bromide  of  potassium  may  be  tried.  Iodide  of 
potassium  has  been  successfully  used  (Keyes). 

PRICKLY  HEAT. 

Called  also  lichen  tropicus  because  it  is  met  with  in  tropical 
climates  in  its  most  typical  form,  is  a  congestion  or  slight  inflam- 
mation at  the  orfices  of  the  sudoriparous  follicles  (Anderson). 

Cause. — Heat  is  the  exciting  cause. 

Symptoms. — Little,  bright  red,  acuminated  papules,  about 
the  size  of  pinheads,  make  their  appearance  in  great  numbers, 
giving  to  the  skin  a  rough  feeling.  They  may  be  closely  set  to- 
gether, but  generally  remain  discrete,  the  intervening  skin  having 
a  healthy  appearance.  Here  and  there  little  vesicles,  such  as  are 
observed  in  sudamina,  often  make  their  appearance.  This  erup- 
tion is  found  chiefly  upon  the  trunk  and  forehead,  and  is  accom- 
panied by  a  tingling,  pricking,  or  itching  sensation.  It  is  aggra- 
vated by  the  use  of  stimulating  food  and  drink,  as  well  as  by 
heat  and  over- clothing.  The  rash  frequently  occurs  in  successive 
crops  and  the  duration  is  indefinite  (Anderson). 

Treatment. — Keep  the  patient  cool.  The  skin  may  be  fre- 
quently sponged  with  vinegar  and  water,  or  a  weak  lotion  of 
carbolic  acid  followed  by  a  soothing  dusting  powder,  such  as 
equal  parts  of  oxide  of  zinc,  lycopodium  and  starch.  The  diet 
should  be  very  light  and  unstimulating.  Saline  aperients  are 
useful,  as  well  as  diuretics  and  cooling  acidulated  drinks 
(Anderson). 

PROSTATITIS. 

Is  an  inflammation  of  the  prostate  gland.  Congestion  of 
the  prostate  occurs  physiologically  during  venereal  excitement. 
If  such  excitement  be  unduly  prolonged  without  being  gratified, 


PROSTATITIS.  457 

or  if  the  imagination  be  given  np  to  erotic  fancies,  the  mucous 
follicles  of  the  organ  secrete  more  or  less  of  a  peculiar,  viscid, 
bluish  mucus,  without  odor,  which  mixed  with  urethral  mucus, 
finds  its  way  out  at  the  meatus.  This  is  perfectly  natural.  It  is 
analogous  to  the  wateriug  of  the  mouth  of  a  hungry  individual 
at  the  sight,  smell,  or  even  thought  of  food.  This  drop  of  mucus 
appearing  during  erection  excites  in  the  minds  of  many  individ- 
uals whose  sexual  requirements  are  not  met,  the  most  lively 
alarm,  and  they  hasten  to  consult  a  physician.  Marriage,  to 
place  him  in  natural  sexual  relations,  will  effect  a  cure.  If  this 
physiological  hyperseinia  be  kept  up  for  a  long  time,  the  prostate 
is  liable  to  remain  congested,  and  cause  frequent  uriuation  and  a 
gleety  discharge.  Slight  congestion  of  the  prostate  frequently 
complicates  gonorrhoea  and  stricture,  and  it  maypassonto  actual 
inflammation.  Congestion  may  be  excited  in  the  prostate  by 
sexual  excess  and  lead  to  prostatitis  (Keyes). 

Causes. — Among  the  causes  of  parenchymatous  prostatitis 
may  be  mentioned  gonorrhoea,  stricture,  extreme  and  prolonged 
sexual  excitement,  acid  urine,  cold,  injury,  strong  injections,  and 
cantharides  internally.  Gonorrhceal  inflammation  after  the  first 
week,  may  run  down  the  urethra  and  involve  the  prostate,  if  the 
patient  indulge  in  alcohol,  sexual  intercourse,  takes  violent  exer- 
cise, or  uses  strong  injections  deep  in  the  canal.  The  inflamma- 
tion behind  a  stricture  may  run  back  to  the  prostate. 

Termination. — Prostatitis  commences  as  congestion  and  passes 
on  to  true  inflammation.  It  terminates  by  resolution  with  exu- 
dation of  pus,  by  abscess,  or  it  may  linger  indefinitely  as  a  chronic 
inflammation  (Keyes). 

Symptoms. — The  prostate  swells  rapidly  and  often  attains 
the  size  of  an  orange.  The  mass  may  be  felt  with  the  finger  in 
the  rectum,  and  is  exceedingly  sensitive  to  pressure,  unlike  hy- 
pertrophy of  the  prostate.  In  prostatitis,  the  finger  in  the  rectum 
or  pressure  over  the  pubes  brings  on  a  desire  to  urinate.  The 
patient  is  conscious  of  something  protruding  into  the  rectum. 
The  perinseum  feels  hot  and  is  sensitive  to  pressure.  There  is  a 
feeling  of  weight  and  dragging  in  the  pelvis,  penis  and  scrotum. 
There  may  be  pain  in  the  back  and  limbs.  The  stream  of  urine 
is  small  and   is  passed  with   effort.     The   prostate  may  swell  to 


458  a  compendium:  of  practical    medicine. 

such  an  extent  as  to  cause  retention.  There  is  a  constantly 
recurring,  never- satisfied  desire  to  urinate.  Voiding  the  urine 
causes  pain,  but  the  pain  is  most  severe  as  the  last  drops  are 
being  expelled.  The  patient  has  fever,  and  is  irritable,  despond- 
ent and  suspicious.  Recovery  is  complete  in  from  one  to  three 
weeks  (Keyes). 

Treatment. — The  main  treatment  is  rest  in  bed  with  hips 
raised,  some  alkaline  diluent  for  the  urine,  and  enough  anodyne 
to  control  severe  pain.  Rectal  injections  of  hot  water  may  be 
given.  The  patient  may  drink  flaxseed- tea,  infusion  of  triticum 
repens  with  some  citrate  of  potash  or  Vichy  water.  If  the  pros- 
tatitis is  due  to  gonorrhoea  all  active  treatment  and  urethral  injec- 
tions must  be  discontinued.  Ten  to  fifteen  leeches  may  be 
applied  to  the  perinseum.  Hot  applications  to  the  pelvis  are 
useful.  At  night  full  doses  of  bromide  of  potassium  with  from 
gr.  v.- xx.  chloral  hydrate  maybe  given  to  produce  sleep  (Keyes). 

PROSTATORRH(EA. 

Is  also  called  follicular  prostatitis:  In  this  disease,  the 
mucous  surface  of  the  sinus  of  the  prostate  and  of  the  mucous 
follicles  and  ducts  are  inflamed,  while  the  substance  of  the  organ 
for  the  most  part  escapes. 

Symptoms. — It  runs  a  chronic  course.  It  may  come  on  dur- 
incr  o-onorrhcea  as  the  inflammation  extends  backward.  The  main 
feature  of  the  disease  is  a  slight  oozing  from  the  meatus  of  a 
niuco- purulent  matter.  The  discharge  may  be  more  profuse 
when  at  stool.  The  patient  thinks  the  discharge  to  be  semen. 
This  discharge  is  exceedingly  rebellious  to  treatment.  If  the 
prostatorrhcea,  or  follicular  prostatitis,  and  the  parenchymatous 
coexist,  then  a  peculiar  weight  is  felt  in  the  perineum  with  pain. 
Walking  becomes  painful.  Crossing  the  legs  decidedly  increases 
the  pain,  as  does  the  sitting  posture.  There  is  frequency  of 
urination.  There  is  pain  on  passing  water,  which  contains  pus 
and  blood.  The  pain  may  be  felt  at  the  end  of  the  penis.  The 
stream  of  urine  is  sometimes  suddenly  interrupted.  The  patient 
may  be  feverish  and  depressed.  A  slight  gleety  discharge  accom- 
panies this  condition  (Keyes). 


PRURIGO.  459 

Treatment. — Xo  remedy  is  so  efficacious  as  blistering  of  the 
perinseum.  Cantharidal  collodion  may  be  painted  on  one  side  of 
the  perinseum,  and  the  patient  confined  to  bed  for  forty -eight 
hours,  then  the  other  side  may  be  painted.  Alkaline  diluents 
may  be  given,  and  the  bowels  kept  regular.  A  good  diet  and 
tonics  are  necessary.  If  this  treatment  fail,  nitrate  of  silver  (gr. 
v.-x.  to  the  5j.)  may  be  injected  into  the  membranous  urethra 
(Key.es). 

PRURIGO. 

Is  a  papular  skin  disease  with  intense  itching. 

Causes. — Very  little  is  known  concerning  its  cause.  The 
fact,  however,  that  it  is  met  with  almost  exclusively  amongst  the 
neglected  children  of  the  poor,  seems  tolead  to  the  conclusion  that 
defective  diet  and  absence  of  rJroper  hygienic  surroundings  are 
favorable  to  its  occurrence  (Anderson). 

Symptoms. — As  a  rule  it  begins  in  infancy,  usually  at  first 
upon  the  legs  in  the  form  of  wheals  like  those  of  nettle-rash.  These 
come  and  go  until  the  child  is  five  to  seven  years  of  age.  At 
this  time  many  solitary  papules,  about  the  size  of  hemp- seeds, 
make  their  appearance.  They  may  be  more  readily  felt  than 
seen.  The  papules  are  irritable  and  soon  become  congested  by 
scratching.  The  skin  assumes  a  dusky  tint  and  is  covered  with 
a  fine  mealy  dust,  and  short  stiff  hairs.  In  some  cases  the  skin 
feels  as  rough  as  a  file  and  is  thickened.  The  papules  may  sup- 
purate. The  eruption  is  more  severe  upon  the  extensor  sur- 
faces of  the  legs  and  arms  than  on  the  flexor  surfaces.  The  trunk 
suffers  some  but  the  head,  neck,  scrotum,  penis,  palms  and  soles 
are  usually  free.  Prurigo  is  a  most  loathsome  disease  when  fully 
developed.  It  is  common  in  parts  of  Europe,  but  is  rarely  met 
with  in  England  and  America  (Anderson). 

Prognosis. — Is  .  very  unfavorable.  Hebra  said  that  the 
jmtient  may  do  whatever  he  pleases  yet  his  malady  will  follow 
him  to  his  grave  ( Anderson). 

Treatment. — The  diet  should  be  generous  and  the  hygienic 
surroundings  good.  Tonics  are  indicated  and  a  long  continued 
course  of  arsenic  in  full  <!<><<•>.  Carbolic  acid  internally  thrice 
daily  is  beneficial.     Local  treatment  is  important.     Warm,  vapor 


460  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

or  Turkish  baths  should  be  ordered.  A  mixture  of  equal  parts 
of  soft  soap,  rectified  spirit  aud  oil  of  cade  may  be  rubbed  firmly 
iuto  the  skin  in  the  morning  and  removed  in  the  bath  at  bedtime, 
after  which  the  following  ointment  may  be  applied: 

R     S  ulphuri? 

Glycerina? 

Olei  rusci aa 3 vi. 

Ung.  rumicis oij-— M. 

Ft.  tfngt. 
Sig. :     Apply  locally. 

In  some  cases  baths  of  corrosive  sublimate,  (oij  to  the  bath) 
are  beneficial  (Anderson). 

PRURITUS. 

Is  a  functional  affection  of  the  skin  characterized  by  irrita- 
tion or  itching  and  unaccompanied  by  eruption.  Pruritus  is  a 
common  affection.  It  may  be  continuous  or  intermittent,*and  is 
most  complained  of  after  getting  warm  in  bed.  It  may  involve 
the  whole  body,  as  we  often  see  in  old  people  whose  health  is 
failing;  but  more  commonly  it  is  localized,  and  the  parts  most 
liable  to  be  attacked  are  the  anus,  the  scrotum,  and  the^labia 
(Anderson). 

Causes. — In  any  case,  it  is  the  result  of  direct  or  reflex  irrita- 
tion of  the  cutaneous  nervous  filaments.  Derangement  of  the 
digestive  organs  and  constipation  may  cause  it.  Diseases  of  the 
kidneys,  uterus  aud  ovaries  may  produce  it.  It  often  results 
from  impediment  to  the  free  return  of  venous  blood  from  the 
part.  It  accompanies  jaundice  and  results  from  the  poisonous 
action  of  the  bile  acids,  circulating  with  the  blood,  upon  the 
nerves  of  the  skin.  A  frequent  source-of  pruritus  is  the. presence 
of  sugar  in  the  urine,  especially  of  that  form  which  attacks  the 
genital  organs.  Elderly  women  who  have  intenseltching  in  and 
around  the  vulva,  probably  have  glycosuria.  Sometimes  the 
cause  of  the  pruritus  disappears,  while  the  itching  continues 
owing  to  the  cutaneous  nervous  filaments  having  contracted  a  bad. 
habit.  Finally,  it  may  result  from  cold,  and  is  then^  chiefly jnet 
with  on  the  lower  extremities  (Anderson). 


PRURITUS PSORIASIS.  461 

Treatment. — Try  to  ascertain  and  remove  the  cause.  If  de- 
pendent on  haemorrhoids,  jaundice,  diabetes  mellitus,  or  digestive 
derangement,  treat  these  morbid  conditions.  If  the  cause  cannot 
be  discovered,  the  treatment  will  be  purely  empirical,  and  in 
these  cases  it  is  desirable  to  have  a  good  many  strings  to  our  bow 
since  the  affection  is  very  obstinate.  In  such  cases  carbolic  acid 
may  be  tried  in  the  following  formula: 

Be     Acidi  carbolici 3ij. 

Sy rupi  aurantii 5J . 

Aquse $v. — M. 

Sig. :     A  teaspoonful  in  a  glass  of  water  three  times  daily  on  an 
empty  stomach. 

Nerve  tonics,  as  strychnine,  phosphorus,  and  arsenic  may  be 
beneficial.  Atropine  may  be  tried  as  a  nerve  sedative.  Dr. 
Bulkley,  of  New  York,  would  give  ten  drops  of  the  tincture  of 
gelsemium  every  half  hour  till  relief  is  obtained,  or  until  one 
drachm  is  taken.  If  these  remedies  fail,  bromide  of  potassium, 
sodium,  or  ammonium  may  be  tried.  Occasionally  relief  is  ob- 
tained by  sponging  the  surface  with  a  warm  decoction  of  poppy 
heads,  or  by  the  application  of  a  weak  continuous  current  of 
electricity.     Alkaline  baths  may  be  tried  (Anderson). 

PSORIASIS. 

Is  a  chronic  eruption  characterized  by  the  appearance  of 
dusky-red,  or  even  coppery,  slightly  elevated  patches  of  various 
sizes,  covered  with  silvery- white,  imbricated,  and  very  adherent 
scales,  with  slight  itching,  but  no  exudation  of  the  surface  of 
the  skin. 

Frequency. — It  is  by  far  the  most  frequent  of  the  affections 
of  the  skin,  except  eczema  and  scabies. 

Parts  Attacked. — The  eruption  may  occur  on  any  part  of 
the  body,  but  in  the  majority  of  cases  it  commences  on  the  elbows 
or  knees,  and  is  frequeutly  limited  to  these  parts.  Next  to  the 
elbows  and  knees  the  head  is  the  part  most  commonly  attacked 
(Anderson). 

Causes. — Are  very  obscure.  Psoriasis  is  an  hereditaiy  dis- 
ease. Sir  E.  Wilson  was  of  the  opinion  that  psoriasis  is  "  a 
manifestation  of  the  syphilitic  poison,  after  transmission  through 


462  A    COMPEXDIUM    OF    PRACTICAL     MEDICINE. 

at  least  one,  and  probably  through  several  generations.1'  There 
is  a  non- syphilitic  and  a  syphilitic  form.  Psoriasis  may  be  in- 
duced by  debility,  but  usually  patients  are  in  ajDparently  good 
health.  Long  continued  mental  fatigue,  as  from  over-study, 
great  anxiety,  etc.,  is  very  apt  to  call  out  the  disease.  It  is  met 
with  in  all  ranks  of  life.  Sea- air  and  sea- water  are  apt  to  call 
out  an  attack  in  one  predisposed  (Anderson).  It  is  severest  in 
the  winter  season. 

Symptoms. — As  a  rule,  psoriasis  does  not  occur  before  the 
sixth  year,  and  usually  comes  out  before  the  age  of  twenty- five. 
It  is  throughout  a  dry  eruption.  It  is  a  non-febrile  affection. 
The  nails  of  the  fingers  and  toes  are  sometimes  affected  and  fall 
off.  At  the  outset  of  the  disease,  little  silvery -white  scattered 
spots  about  the  size  of  pin-heads  make  their  appearance.  As  the 
disease  advances,  these  spots  may  increase  in  size,  being  two  to 
three  inches  in  diameter.  There  is  scarcely  any  itching.  It  is 
not  contagious,  but  can  often  be  traced  to  hereditary  taint.  The 
eruption  may  be  on  any  part  of  the  body,  but  almost  always  on 
the  elbows  and  knees.  Relapses  are  the  rule.  Psoriasis  may 
last  five,  ten,  fifteen,  twenty  or  thirty  years,  or  even  a  whole 
lifetime  (xAnderson). 

Prognosis. — The  disease  is  not  fatal,  but  relapses  are 
common. 

Treatment. — The  patient  should  take  a  course  of  baths,  have 
plenty  of  fresh  air,  take  his  meals  at  regular  hours,  go  to  bed 
early,  rise  early,  and  have  nothing  to  worry  him.  We  should 
tone  up  the  digestive  powers.  Nitro- muriatic  acid  and  gentian 
often  do  good.  Balsam  of  copaiba  is  occasionally  of  service. 
Tar  and  carbolic  acid  internally  are  often  effectual.  Liquor 
potassse  in  doses  of  from  twenty  to  thirty  drops  thrice  daily  in 
water  is  highly  praised.  Acetate  of  potash  in  doses  of  one-half 
drachm  thrice  daily  is  beneficial.  A  course  of  carbonate  of 
ammonia  may  be  tried,  also  strychnia.  Arsenic  is  the  most 
valuable  internal  remedy  which  we  possess  in  the  treatment  of 
23soriasis,  and  few  cases  resist  it  if  given  long  enough.  Five  or 
six  drops  of  Fowler's  solution  may  be  given  thrice  daily  after 
meals.  It  agrees  better  with  the  stomach  if  given  in  bitter 
infusion — gentian.     Xext  in  value  to  arsenic  comes  cod-liver  oil. 


PUERPERAL    FEVER.  463 

The  two  may  be  combined.  The  syrup  of  the  iodide  of  iron 
may  be  given  also.  Some  cases  are  cured  by  a  course  of  Bant- 
ingism — i.  e.,  by  a  meat  diet.  The  patient  should  be  urged  to 
eschew  a  too  sedentary  mode  of  life,  to  take  open  air  exercise, 
and  to  try  change  of  air  and  scene.  Local  treatment  is  of  much 
value.  Warm  baths  and  soothing  ointments  may  be  used.  Cold 
cream,  cucumber  ointment,  the  benzoated  oxide  of  zinc  ointment, 
ointment  of  carbonate  or  subacetate  of  lead,  or  a  mixture  of  zinc 
and  almond  oil  may  be  employed  with  advantage — three  or  four 
applications  daily.  The  hydropathic  treatment  may  be  tried. 
Chrysophanic  acid  may  be  used  in  the  form  of  an  ointment,  as 
follows : 

JJr     Acidi  chrysophanici gr.  x. 

A  dipis 3] . 

Lanolini , , . .  §j . — M. 

Sig. :     Use  locally  night  and  morning. 

PUERPERAL  FEVER. 

Is  an  infectious  disease,  due  as  a  rule,  to  the  septic  inocula- 
tion of  the  wounds  which  resuult  from  the  separation  of  the  de- 
cidua  and  the  passage  of  the  child  through  the  genital  canal  in 
the  act  of  parturition  (Lusk). 

Frequency. — The  total  number  of  deaths  to  the  entire  num- 
ber of  confinements  is  estimated  to  be  in  the  proportion  of  1  to 
85,  or  from  puerperal  fever  alone  in  the  proportion  of  1  to  146 
(Lusk). 

Causes. — One  source  of  puerperal  fever  is  a  contaminated 
atmosphere.  Another  and  frequent  source  of  puerperal  fever  is 
by  direct  inoculation.  Any  material  of  a  septic  character,  in- 
troduced into  the  genital  passages  of  a  woman  during  or  after 
confinement,  may  produce  a  general  infection  of  the  system. 
Pathogenic  bacteria  are  invariably  associated  with  puerperal 
fever,  and  to  them  the  infectious  qualities  of  the  disease  are  due. 
Puerperal  fever  is  really  a  surgical  fever  modified,  however,  by 
the  peculiar  physiological  conditions  which  belong  to  the  puer- 
peral state.  It  is  a  matter  of  ordinary  experience  that  the  reten- 
tion of  a  small  bit  of  the  membranes  within  the  uterus  will  pro- 
duce fetid  lochia,  and  as  the  result  of  infection,  a  febrile  condi- 


464  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tiou  which  as  a  rule,  subsides  with  the  expulsion  of  the  offend- 
ing body  and  the  use  of  disinfectant  washes  (Lusk). 

Prevention. — The  physician  should  insist  upon  the  value  of 
plenty  of  light  and  fresh  air  as  a  means  of  contributing  to  the 
speedy  recovery  of  child-bed  women,  otherwise  they  may  become 
poisoned  with  their  own  exhalations.  Complete  antisepsis  be- 
fore confinement  will  prevent  the  introduction  of  germs  and  after 
confinement  will  paralyze  their  action.  Employ  means  to  pro- 
mote uterine  contraction.  Refrain  from  attending  a  case  of  labor 
when  fresh  from  the  presence  of  contagious  diseases  or  septic 
material.  In  every  case  of  labor  the  hands  and  forearms  should 
be  freely  bathed  in  a  carbolic  solution  before  making  a  vaginal 
examination.  All  instruments  employed  during  confinement 
should  be  disinfected.  The  warm  carbolized  douche  after  deliv- 
ery stimulates  uterine  retraction  and  promotes  the  rapid  healing 
of  wounds  in  the  vaginal  canal.  The  fountain  syringe  should  be 
used  (Lusk). 

Symptoms. — The  first  febrile  symptoms  usually  occur  within 
three  days  of  the  birth  of  the  child.  The  third  clay  is  the  one 
upon  which,  ordinarily,  the  beginning  of  the  fever  is  to  be  antici- 
pated. After  the  fifth  day  an  attack  is  rare.  In  most  cases  the 
fever  is  ushered  in  by  chilly  sensations,  or  by  a  well-defined  chill. 
A  frequent  pulse  is  always  a  suspicious  symptom  in  childbed, 
even  where  the  other  symptoms  are  apparently  normal.  There 
may  be  headache,  sleeplessness,  pain,  vomiting,  anorexia,  and 
coated  tongue  (Lusk). 

Treatment. — It  is  to  be  recommended  that  in  every  case  of 
puerperal  fever,  the  vagina  be  cleansed  with  a  two  to  three  per 
cent,  solution  of  carbolic  acid,  or  corrosive  sublimate  (1:3,000) 
every  four  to  six  hours.  The  douche  in  itself  is  absolutely  harm- 
less. No  portion  of  the  injected  fiuid  should  be  retained  in  the 
vagina.  All  necrotic  patches  of  the  vagina  or  cervix  should  be 
touched  with  hydrochloric  acid,  or  with  a  ten  per  cent,  solution 
of  carbolic  acid,  or  with  iodoform.  Intra -uterine  injections 
should  be  resorted  to  with  extreme  circumspection.  Rarely  are 
they  indicated.  Opium  must  be  given  for  the  pain.  Purgatives 
(castor-oil  in  two  or  three  tablespoonful  doses)  should  be  ad- 
ministered with  caution.     For  the  fever  quinia  may  be  adminis- 


PURPURA.  465 

tered  in  five  grain  doses  at  intervals  of  four  to  six  hours.  Stimu- 
lants in  the  form  of  whiskey,  rum,  or  brandy  may  be  given  in 
doses  of  one  or  two  teaspoonfuls  hourly.  Ice-cold  drinks  should 
be  freely  allowed  (Lusk). 

PURPURA. 

Is  a  general  disease,  characterized  by  circumscribed  extra- 
vasations of  blood  into  the  skin  (Loomis).  Purpura  may  be 
simple,  rheumatic,  hemorrhagic,  or  symptomatic.  In  simple  pur- 
pura there  are  only  minute  extravasations  into  the  skin  (petechias); 
in  rheumatic  purpura  there  is  a  combination  of  purpura  and 
rheumatic  pains  in  the  joints;  in  hemorrhagic  purpura  there  is 
great  constitutional  disturbance,  petechias  not  only  appear  in 
the  skin,  but  ecchymoses,  and  there  may  be  hemorrhage  from  all 
the  mucous  tracts;  in  symptomatic  purpura,  the  purpuric  spots 
accompany  the  exanthems  and  contagious  fevers,  and  are  purely 
symptomatic  (Bartholow,  Loomis  and  Flint). 

Morbid  Anatomy. — There  are  changes  in  the  walls  of  the 
vessels,  or  in  the  blood,  or  in  both  (Loomis). 

Causes. — Purpura  occurs  more  frequently  in  women  than  in 
men.  It  may  appear  in  the  healthy  and  robust.  The  leading 
causes  are  bites  of  insects,  passive  congestion,  various  drugs,  such 
as  iodide  of  potassium,  phosphorus,  cojDaiba,  ergot,  chloral,  and 
mercury;  snake-bites,  embolism  and  thrombosis  of  cutaneous 
vessels,  cachexias,  as  tuberculosis,  cancer,  Bright's  disease,  cirrhosis 
of  the  liver,  anaemia,  leucocythasmia;  diseases  of  the  nervous 
system,  small -pox,  typhus  and  typhoid  fevers,  measels,  scarlet 
fever,  malaria,  cholera,  yellow  fever,  cerebro- spinal  meningitis, 
icterus,  scorbutus,  etc.  Purpura  may  be  accidentally  present  in 
the  course  of  any  disease  (Flint). 

Symptoms, — In  many  cases  for  days  before  the  eruption 
appears,  there  is  a  feeling  of  malaise  with  digestive  derangement. 
Purpuric  spots  are  bright-red,  livid,  or  dark  purplish -red  in  color, 
they  do  not  disappear  on  pressure,  and  are  unattended  by  itching 
or  other  signs  of  local  irritation.  As  a  rule  the  sj>ots  are  not 
elevated.  They  vary  in  size  from  a  pin's  head  to  a  large  pea,  or 
a  spot  may  measure  an  inch  in  circumference,  and  change  in  color 


466  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

successively  from  bluish -red  to  greenish,  brown,  and  yellow.  It 
is  more  common  from  fifteen  to  twenty  than  at  any  other  age. 
In  ordinary  cases  a  crop  of  purpuric  spots  lasts  from  a  week  to 
ten  days,  and  usually  first  apppear  on  the  legs.  Purpura  is 
common  in  fruit  seasons  (Bartholow,  Da  Costa  and  Flint). 

Differential  Diagnosis. — Purpura  may  be  confounded  with 
scurvy  and  skvn  diseases.  From  scurvy  it  is  distinguished  by  the 
absence  of  spongy  gums  and  painful  swellings.  The  fact  that 
there  is  no  itching,  no  desquamation,  no  suppuration  or  discharge, 
and  no  change  in  purpuric  spots  upon  pressure  suffices  to  dis- 
tinguish them  from  the  eruption  of  any  form  of  skin  disease 
(Loomis). 

Prognosis. — Most  cases  terminate  in  recovery. 

Treatment. — The  diet  should  be  nutritious  and  varied,  and 
digestion  is  to  be  aided  by  tonic  remedies,  together  with  wine  or 
spirits  in  small  quantities.  Dilute  sulphuric  acid  may  be  given 
in  doses  of  from  five  to  fifteen  drops  every  two  hours  combined 
with  quinia.  Ergot,  gallic  acid,  and  tincture  of  the  chloride  of 
iron  may  be  of  service  (Flint). 

PYEMIA. 

Is  an  infectious  disease,  characterized  by  the  formation  of 
infarctions,  metastatic  abscesses  and  diffuse  local  infiammation. 
Venous  thrombosis  and  embolism  are  essential  features  of  this 
disease,  and  cause  metastatic  abscesses  in  the  lungs,  liver, 
kidneys,  spleen,  muscles,  heart  and  brain.  Metastatic  abscesses 
vary  in  size  from  a  pea  to  a  large  walnut  (Loomis). 

Causes. — Many  regard  the  pyaeinic  and  septicaeinic  poison  as 
identical,  and  pyaemia  as  nothing  but  a  metatistic  septicaemia. 
Inflammation  of  bone  is  a  very  frequent  cause  of  a  phlebitis 
which  leads  to  pyaemic  infection.  Cellulitis,  carbuncle,  erysipe- 
las, malignant  pustule,  and  dissecting  wounds  are  often  compli- 
cated by  pyaemia.  Endometritis  or  lacerations  about  the  genital 
tract  are  fruitful  sources  of  pyaemia  in  the  puerperal  state 
(Loomis). 

Symptoms. — Pyaemia  is  ushered  in  by  a  distinct  chill  or  rigor 
followed  by  a  gradual  rise  of  temperature  to  101°  or  10-1  °  F.  The 


PYJEMIA PYROSIS.  467 

chills  of  pyaemia  occur  irregularly,  aucl  are  followed,  after  the 
first  two  or  three,  by  profuse  and  exhausting  sweats.  The  pulse 
is  frequent,  120  to  140,  small  and  often  intermittent.  The  skin 
may  be  jaundiced.  The  breath  has  a  peculiarly  sweet,  sickish 
•  odor.  The  tongue  becomes  coated,  glazed,  dry,  brown  and  fis- 
sured. Sordes  collect  on  the  teeth.  There  are  anorexia  and 
great  thirst.  There  is  usually  diarrhoea  with  nausea  aud  vomit- 
ing (Loomis). 

Differential  Diagnosis. — The  diagnostic  points  of  pyaemia  are, 
irregularly  recurring  chills  and  sweats,  great  variations  in  tem- 
perature, with  the  signs  of  multiple  abscess  in  the  internal 
organs.  Pyaemia  may  be  confounded  with  septicaemia,  intermit- 
tent fever,  acute  yellow  atrophy  of  the  liver,  acute  articular 
rheumatism,  typhus  and  typhoid  fever. 

JPywmia  is  ushered  in  by  a  distinct  chill;  septicaemia  by 
slight  shivering,  or  mild  rigors  only.  In  pyaemia  the  chills  recur; 
in  septicaemia  there  is  but  one  chill.  In  pyaemia  there  are 
profuse  sweats  which  recur;  in  septicaemia,  they  are  slight  and 
never  recur.  In  pyaemia  the  temperature  gradually  rises  to 
102°  to  104°  F.;  in  septicaemia  it  is  high  at  the  onset,  105°  to 
107°  F.  In  pyaemia  the  skin  is  jaundiced;  not  so  in  septicaemia. 
There  is  a  sweet,  sickish  odor  to  the  breath  in  pyaemia,  absent 
in  septicaemia.  In  pyaemia  multiple  abscesses  develop,  never  in 
septicaemia  (Loomis). 

Prognosis. — Is  always  unfavorable. 

Treatment. — Cleanliness,  good  ventilation,  sunlight  and  quiet 
are  important  measures.  Quinia,  carbolic  acid,  salicylic  acid 
and  oil  of  turpentine  may  be  used  internally.  A  good  diet  and 
stimulants  should  be  administered  in  large  quantities  (Loomis). 

PYROSIS. 

The  regurgitation  of  a  considerable  quantity  of  a  liquid 
which  is  either  insipid  or  saltish  or  brackish  and  is  sometimes 
acid  when  the  stomach  is  empty  of  food  and  usually  in  the  morn- 
ing is  called  pyrosis  or  waterbrash.  This  liquid  consists  mainly 
of  saliva.  Sometimes  there  is  not  only  a  feeling  of  oppression  in 
the  thorax  but  a  severe  pain  is  referred  to  the  heart  accompanied 


468  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

by  palpitation  and  dyspnoea.  In  such  cases  the  patient  is  very 
apt  to  imagine  he  has  heart  disease.  Pyrosis  is  not  a  disease  but 
a  symptom  of  certain  cases  of  gastric  dyspepsia  (Flint  and 
Loomis). 

PARAPHIMOSIS. 

Exists  where  the  prepuce  gets  behind  the  corona  glandis 
and  cannot  be  replaced  (Keyes). 

Causes. — An  unnaturally  tight  preputial  orifice  is  a  predis- 
posing cause.  Young  boys  who  retract  the  prepuce  for.  the  first 
time  often  find  themselves  unable  to  replace  it.  Rings  of  metal 
forced  upon  the  penis  retracting  the  prepuce  may  be  a  cause. 
Inflammatory  paraphimosis  may  depend  upon  balanitis,  gon- 
orrhoea, herpes,  chancroid,  chancre,  etc.  (Keyes). 

Symptoms. — In  rjaraphirnosis  the  glans  penis  is  swollen  and 
livid.  If  the  patient  is  seen  at  once,  there  may  be  no  inflamma- 
tion, either  of  the  prepuce  or  the  glans.  If  the  stricture  of  the 
prepuce  is  tight  enough  to  arrest  the  circulation  it  will  cause 
gangrene  (Keyes). 

Treatment. — /.  Of  paraphimosis  with  strangulation.  In 
strangulation  the  glans  penis  is  turgid,  swollen,  blue-black,  cold 
and  devoid  of  sensibility.  Ice  should  be  first  used  locally  to 
produce  shrinkage  and  a  few  small  punctures  may  be  made  to 
let  out  serum  from  the  ridge  in  front  of  the  stricture.  In  these 
cases  ether  should  always  be  given  to  relax  the  tissues  and  reduc- 
tion attempted.  If  a  prolonged,  careful  attempt  at  reduction 
fails,  the  strictured  point  must  be  divided.  After  reduction  the 
treatment  consists  in  position,  rest  and  cleanliness,  syringing  the 
preputial  cavity  with  warm  water. 

II.  Of  paraphimosis  without  strangulation. — In  recent 
cases  reduction  must  be  effected  or  inflammation  will  surely  set 
in.  Reduction  may  be  accomplished  by  using  the  above  means 
(Keyes). 

PHIMOSIS. 

Exists  where  the  orifice  of  the  prepuce  is  so  small  that  the 
glans  penis  can  not  be  uncovered.  Phimosis  is  congenital  or 
acquired,  simple  or  inflammatory,  complicated  by  other  diseases, 


phimosis.  460 

or  by  adhesions.  With  very  young  children,  phimosis  is  so 
common  that  it  may  he  considered  normal.  The  foreskin  of  a 
child  is  developed  out  of  all  proportion  to  the  rest  of  the  penis. 
This  long  prepuce  is  often  a  source  of  anxiety  to  young  mothers. 
A  positive  indication  for  operation,  in  the  case  of  a  child,  does 
exist,  where  the  preputial  orifice  is  smaller  than  that  of  the 
urethra.  This  condition  is  known  to  exist  when  the  prepuce 
"balloons"  during  micturition.  When  the  prepuce  is  too  tight 
in  the  adult,  an  operation  may  be  called  for  as  a  prophylactic 
against  future  disease,  such  as  chancre,  chancroid,  gonorrhoea,  or 
an  attack  of  herpes  (Keyes). 

Causes. — Phimosis  may  be  caused  by  frequent  attacks  of 
preputial  inflammation,  leaving  a  thick,  long,  indurated,  inelastic 
prepuce,  interfering  not  only  with  sexual  intercourse,  but  some- 
times with  urination.  Another  common  cause  of  acquired  phi- 
mosis is  the  cicatrization  of  multiple  chancroid  around  the  orifice 
of  the  prepuce.  Diabetes  is  said  to  be  a  cause  of  phimosis. 
Marx  reported  a  case  of  phimosis  where  a  passionate  and  jealous 
woman  made  her  lover  wear  a  gold  padlock  (sometimes  two) 
with  which  she  secured  the  preputial  orifice,  keeping  the  key 
herself.  The  victim  of  her  charms  carried  his  padlocks,  which 
were  replaced  from  time  to  time  through  new  punctures,  during 
four  or  five  years,  until  such  a  degree  of  irritation  had  been  set 
up  as  to  require  removal  of  the  prepuce.  Inflammatory  phimosis 
is  a  transient  condition,  but  may  leave  true  phimosis  behind 
(Keyes). 

Treatment. — It  is  better  not  to  circumcise  when  the  prepuce 
is  inflamed,  if  it  can  be  avoided.  Keep  the  patient  in  bed,  and 
elevate  the  penis.  Evaporating  lotions  may  be  used  locally,  con- 
taining a  little  spirit  or  a  (gr.  x.-xx. )  solution  of  tannin,  fre- 
quently washing  out  the  cavity  of  the  prepuce  by  means  of  a 
syringe  with  dilute  lead-water  or  carbolic  acid  (gr.  ij.  to  the  gj-.). 

Remote  Results  of  Phimosis. — It  leads  to  imperfect  develop- 
ment of  the  glans  j^enis,  is  an  obstacle  to  sexual  intercourse, 
causes  spermatorrhoea,  frequent  desire  to  urinate  and  cystitis. 
According  to  Dr.  Sayre,  of  New  York,  phimosis  may  cause 
curvature  of  the  spine  in  children,  and  priapism  (Keyes). 


470  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

PTERYGIUM. 

Is  a  triangular  thickening  of  the  conjunctiva,  which  ad- 
vances from  the  caruncle  to  the  cornea  and  encroaches  more  or 
less  upon  the  surface.  The  favorite  site  is  the  inner  side  of  the 
eyeball.  The  structure  grows  very  slowly.  It  may  impair  sight 
before  it  reaches  the  pupilary  area.  The  apex  is  more  or  less 
rounded  and  seems  to  dip  into  the  substance  of  the  cornea.  The 
edges  near  the  apex  will  be  found  to  be  rolled  under  and  will 
admit  a  fine  probe  to  be  thrust  beneath  for  a  short  distance.  It 
appears  mostly  in  persons  who  are  exposed  much  to  the  weather, 
or  to  dust,  and  who  are  of  advanced  age.  A  variety  of  fleshy 
ptergium  may  occur  at  any  portion  of  the  eye  (Noyes). 

Treatment. — Is  surgical  and  preferably  by  excision.  Seize 
the  corneal  portion  with  toothed  forceps  and  as  it  is  lifted,  push 
beneath  it  a  cataract  knife  and  shave  it  from  the  cornea.  Cut 
away  as  much  of  the  base  as  may  be  needful.  The  raw  surface 
may  be  covered  by  flaps  of  the  adjacent  conjunctiva  sutured  by 
silk.  Cocaine  will  annul  the  pain.  An  opacity  of  the  cornea  is 
left,  which  will  continue  for  months.  It  may  ultimately  dis- 
appear (Noyes). 

PYELITIS. 

Is  an  inflammation  of  the  mucous  membrane  of  the  pelvis  of 
the  kidney.  There  is  hyperemia  of  the  mucous  membrane,  and 
exudation  of  pus  and  mucous  takes  place.  In  many  cases  with 
profuse  production  of  pus  there  is  an  obstacle  to  the  passage  of 
the  urine,  and  the  pus  is  retained  in  the  dilated  pel  vis,  causing  the 
condition  known  as  pyonephrosis  (Flint). 

Causes. — Pyelitis  is  seldom,  if  ever,  a  primary  disease.  Its 
most  frequent  cause  is  the  presence  of  calculi  in  the  pelvis  of  the 
kidney.  Obstruction  to  the  flow  of  urine  is  a  cause  of  pyelitis. 
Such  obstructions  are  furnished  by  calculi,  tumors  pressing  on 
the  ureter,  enlarged  prostate,  stricture  of  the  urethra,  phimosis, 
and  paralysis  of  the  bladder  in  cases  of  paraplegia.  In  these 
cases  the  urine  is  retained  and  decomposes,  and  thus  produces 
irritation.  The  pressure  of  a  retroverted  or  pregnant  uterus  may 
cause  obstruction  to  the  flow  of  urine.     Pyelitis  may  be   due  to 


PYELITIS.  471 

gonorrhoea,  specific  vaginitis,  and  urethritis  in  females.  In  these 
cases  cystitis  is  nearly  always  present.  Copaiba,  turpentine,  and 
cantharides  passing  through  the  kidneys  may  cause  pyelitis. 
Pyelitis  may  be  a  complication  in  jDysernia,  puerperal  fever  and 
the  exanthemata  (Bartholow,  Flint  and  Loomis). 

Symptoms. — Pain  in  the  back  is  present  in  the  mild  as  well 
as  in  the  severe  cases.  This  pain,  as  a  rule,  is  severest  over  one 
or  both  lumbar  regions,  is  often  of  an  aching  character,  and 
shoots  down  along  the  course  of  the  ureters.  The  voiding  of 
urine  is  almost  incessant,  and  is  attended  by  severe  pain.  Acute 
pyelitis  is  usually  ushered  in  with  rigors.  Symptoms  of  hectic 
fever  may  also  mark  the  occurrence  of  permanent  obstruction  of 
the  ureter  and  the  development  of  that  condition  termed  pyone 
phrosis.  There  is  lassitude  and  more  or  less  pain  on  motion. 
There  are  changes  in  the  urine.  In  its  early  stage  the  urine 
contains  blood  mixed  with  mucus  and  epithelium  cells  from  the 
pelvis  of  the  kidney.  The  presence  of  these  epithelial  cells  is 
its  most  certain  diagnostic  indication.  The  specific  gravity  of  the 
urine  ranges  from  1025  to  1030,  and  usually  has  an  acid  reac- 
tion. The  urine  may  be  ammoniacal.  Calculous  pyelitis  is 
attended  with  more  pain  and  hemorrhage  than  the  other  forms. 
In  the  advanced  stage  of  pyelitis,  the  discharge  of  pus  is  con- 
stant, but  if  the  ureter  becomes  blocked,  for  a  time  the  urine 
may  be  quite  normal,  but  the  removal  of  the  obstruction  is  fol- 
lowed by  a  copious  flow  of  purulent  urine.  If  there  be  perma- 
nent obstruction  in  the  ureter,  a  tumor  develops  in  the  lumbar 
region.  The  existence  of  the  tumor  is  determined  by  the  pres- 
ence of  bulging  between  the  crest  of  the  ilium  and  the  false  ribs 
on  the  side  involved.  Palpation  shows  deep-seated  fluctuation 
over  the  tumor  and  tenderness  on  pressure.  Percussion  shows 
dullness  over  the  tumor.  A  hypodermic  needle  will  complete 
the  diagnosis  (Bartholow,  Flint  and  Loomis). 

Differential  Diagnosis. — The  diagnosis  of  pyelitis  in  the  acute 
stage  rests  mainly  on  the  presence  of  the  characteristic  epithe- 
lium of  the  pelvis  mixed  with  blood  and  mucus.  In  a  more 
advanced  stage,  in  addition  to  the  above,  there  is  pus.  The 
presence  of  pus  and  acid  urine,  with  pain  in  the  lumbar  region, 
accompanied  by  the  development  of  a  tumor  at  the  seat  of  pain, 


472  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

which  tumor  gradually  increases  in  size  and  suddenly  disappears 
at  the  same  time  that  a  copious  discharge  of  pus  takes  place  from 
the  bladder,  which  discharge  is  attended  by  a  sense  of  great 
relief  to  the  patient,  renders  the  diagnosis  of  pyonephrosis  very 
certain. 

.Pyonephrosis  may  be  confounded  with  hydronephrosis, 
hydatid  cyst  and  perinephritic  abscess.  Hydronephrosis  is  dis- 
tinguished from  pyonephrosis  by  the  non-purulent  character  of 
the  urine,  and  by  the  absence  of  constitutional  symptoms.  An 
aspirating  needle  will  generally  decide  the  diagnosis.  In 
perinephritic  abscess  neither  pus,  blood,  mucus,  epithelia  nor  al- 
bumen will  be  found  in  the  urine;  in  pyonephrosis  they  are 
common  and  constant.  Pain  on  motion  and  fever  are  marked 
symptoms  in  abscess  and  slight  or  absent  in  pyonephrosis.  In 
women  a  pyonephrotic  tumor  has  been  confounded  with  an 
ovarian  cyst.  The  exploring  trocar  will  very  quickly  remove  all 
doubts.  Pyelitis  is  distinguished  from  cystitis  by  the  absence 
of  vesical  pain  and  frequent  micturition  and  by  lumbar  pain.  In 
pyelitis  the  urine  is  acid;  in  cystitis  it  is  alkaline  (Loomis). 

Prognosis, — Depends  much  on  its  causes. 

Treatment. — Eemove  the  cause  if  possible.  In  acute  pyelitis 
if  there  be  fever,  pain,  and  bloody  urine,  wet  cups  should  be  ap- 
plied to  the  loins  followed  by  a  hot  bath  and  a  hypodermic  of 
morphine  to  relieve  pain.  Alkaline  drinks  should  be  given  and 
the  patient  kept  in  bed.  If  the  urine  is  acid,  liq.  potassii  citratis 
should  be  given.  In  ammoniacal  urine  benzoic  acid  is  extremely 
serviceable.  In  chronic  pyelitis,  eucalyptol,  oils  of  turpentine, 
copaiba  and  cubeb  limit  the  formation  of  pus.  Cod-liver  oil  and 
quinine  should  be  given  with  a  nutritious  and  non- stimulating 
diet.  Alkaline  mineral  water  and  milk  should  be  freely  given. 
If  a  tumor  exist  aspiration  may  be  performed  (Bartholow  and 
Loomis). 

PICA  AND  MALACIA. 

Are  terms  applied  to  perversions  of  appetite.  Malacia  de- 
notes a  morbid  craving  for  certain  articles  of  food,  whereas  pica 
denotes  a  desire  for  innutritions  substances.  The  era  vino-  for 
strange  kinds  of  food  during  pregnancy  and  in  hysterical  women 


PICA    AXD    MALACIA POLYPHAGIA.  473 

is  familiar  to  all.  The  innutritious  substances  frequently  craved 
are  charcoal,  chalk,  slate,  and  certain  kinds  of  earth.  In  some 
cases  of  pica  the  articles  are  at  first  taken  with  the  idea  of  im- 
proving the  complexion  and  in  this  way  the  habit  is  formed;  but 
in  other  cases  a  morbid  uneasiness  in  the  stomach  leads  to  their 
use.  This  appetite  is  chiefly  confined  to  young  females  and  is 
generally  associated  with  anseinia  or  chlorosis. 

Treatment. — Treat  the  associated  disorders  and  prohibit  the 
use  of  the  above  substances  (Flint). 

POLYPHAGIA. 

Called  also  bulimia  denotes  a  craving  for  food  beyond  the 
wants  of  the  system.  These  terms  are  not  correctly  applied  to 
the  increased  appetite  during  convalescence  from  fevers  or  other 
acute  diseases.  In  true  bulimia  the  amount  of  food  craved  far 
exceeds  the  requirements  for  nutrition.  BuMmiam&y  be  another 
name  for  gluttony.  The  love  of  eating  may  be  cultivated  to  such 
an  extent  that  little  else  is  thought  of,  and  persons  who  fall  into 
this  habit  may  be  said  to  live  to  eat,  rather  than  to  eat  to  live. 
Habits  of  gluttony  may  lead  to  dyspepsia,  obesity,  fatty  degen- 
eration of  the  heart  and  to  various  affections.  Bulimia  may  be 
a  symptom  of  mental  disease,  or  of  diabetes.  Cases  have  been 
reported  in  which  the  morbid  appetite  appeared  to  be  insatiable, 
all  kinds  of  food — raw  meat,  candles  etc., — being  eaten  in  some 
cases  with  avidity  and  in  enormous  quantity  (Flint). 

Treatment. — Recovery  from  this  condition  is  to  be  expected. 
The  indications  are  to  regulate  the  diet,  to  establish  the  general 
health,  to  correct  any  disorder  of  digestion,  and  to  palliate  the 
excessive  craving  for  food  by  opium,  or  sometimes  by  nauseant 
remedies.  Swallowing  pieces  of  ice  has  been  found  effective  as 
a  palliative  measure  (Flint). 

PARALYSIS  AQITANS. 

Sometimes  called  Parkinson's  disease,  or  shaking  pals)',  or 
the  trembles,  is  a  disease  of  advanced  life  characterized  by  motor 
weakness  and  tremors  of  the  voluntary  muscles,  especially  of  the 
limbs,  occurring  independently  of  muscular  exertion  (Loomis). 


474  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Morbid  Anatomy. — Paralysis  agitans  is  a  neurosis,  a  func- 
tional disorder.  As  yet  no  constant  changes  have  been  dis- 
covered. Some  authorities  consider  it  of  spinal,  others  of  cere- 
bral origin  (Bartholow  and  Loomis). 

Causes. — It  rarely  occurs  before  forty,  and  is  more  common 
in  men  than  women.  It  is  not  known  to  be  hereditary.  The 
jjrincipal  causes  are  strong  emotion,  fright,  grief,  anxiety,  dis- 
tress of  mind,  great  bodily  fatigue,  and  exj)osure  to  cold  and 
dampness  (Bartholow  and  Loomis). 

Symptoms. — Tremor  is  the  chief  symptom  of  paralysis  agi- 
tans. The  trembling  consists  of  fine  small  movements.  Paraly- 
sis agitans  comes  on  slowly,  and  progresses  slowly.  It  usually 
begins  in  one  foot,  hand  or  possibly  a  single  finger,  and  gradu- 
ally becomes  general.  The  tremors  are  often  confined  to  one 
side  of  the  body  for  a  long  time — hemiplegic  type;  less  fre- 
quently to  both  lower  extremities — paraplegic  type.  Any  effort 
of  the  will,  as  grasping,  writing,  or  walking,  will  stop  the  irreg- 
ular motions.  Sometimes  the  disease  sets  in  abruptly  in  conse- 
quence of  some  sudden  shock.  Mental  emotion  and  exercise  in- 
crease the  trembling,  and  sleep  and  chloroform  narcosis  suspend 
it.  The  trembling  consists  in  muscular  contractions  and  relaxa- 
tions. The  hands  are  apt  to  assume  a  position  as  in  writing. 
As  a  rule,  the  head  and  neck  are  not  affected.  The  countenance 
assumes  a  fixed,  staring  look  of  distress,  the  head  is  drawn  for- 
ward and  the  trunk  fiexed.  The  voice  is  often  tremulous  and 
speech  is  slow,  hesitating  and  laborious.  The  muscles  are  easily 
tired.  The  patient  rises  slowly  and  is  deliberate  in  starting,  but 
when  under  way,  he  goes  in  a  dog- trot  with  the  head  and  body 
bent  forward  (festination).  Complaints  are  made  of  cramps,  of 
muscular  stiffness,  of  a  sense  of  excessive  heat,  and  of  restless- 
ness. The  knee-jerk  is  normal  (Bartholow,  DaCosta,  Flint  and 
Loomis). 

Prognosis. — Although  the  disease  may  last  for  twenty  or 
thirty  years,  death  most  commonly  results  from  some  intercur- 
rent disease.     The  outlook  is  never  favorable  (Loomis). 

Differential  Diagnosis. — Paralysis  agitans  may  be  confounded 
with  disseminated  sclerosis,  senile  trembling,  alcoholic,  lead  and 
meruwrial  trembling '.     In   disseminated   sclerosis   tremors  occur 


RACHITIS.  475 

onlv  when  the  muscles  are  in  use;  the  disease  beo-insin  the  lower 
limbs,  affects  younger  persons,  and  paralysis  occurs  early.  The 
patient  has  no  tendency  to  run  forward  and  does  not  have  the 
peculiar  countenance.  In  paralysis  agitans  the  tremor  is  not 
dependent  on  volition;  it  begins  in  the  upper  limbs,  and  per- 
sons under  forty  years  are  exempt  from  this  affection.  Paralysis 
occurs  late.  The  patient  has  a  tendency  to  run  forward  and  has 
a  fixed,  staring  countenance.  In  senile  trembling  the  head  is 
chiefly  affected  and  there  is  no  paresis  of  muscles,  no  stiffness,  no 
deformity  of  the  extremities,  and  no  impulse  to  run  forward. 
Alcoholic,  lead  and  mercurial  trembling  are  readily  diagnosti- 
cated by  the  previous  history  (Bartholow,  Flint  and  Loomis). 

Treatment. — Xo  plan  of  treatment  is  satisfactory.  Hyoscy- 
amine,  according  to  Charcot,  is  the  best  remedy  to  moderate  the 
trembling.  Gelsemium  is  useful.  The  chloride  of  gold  and  so- 
dium, corrosive  sublimate  in  small  doses,  nitrate  of  silver,  and 
the  lactophosphate  of  lime  with  arsenic  may  be  tried.  The  gal- 
vanic current  may  be  tried  (Bartholow  and  Loomis). 

RACHITIS. 

Called  also  rickets,  rachitismus  and  osteomalacia,  is  a  con- 
stitutional disease  of  the  first  years  of  life,  characterized  by  a 
disorder  of  nutrition  in  which  the  growth  of  the  bones  is  irregu- 
lar, calcification  imperfect,  and  deformities  ensue  (Bartholow). 

Causes. — Rickets  is  a  common  result  of  faulty  diet  and  of 
anti-hygienic  surroundings,  and  is  therefore  frequent  among  the 
poor  of  cities,  and  especially  in  families  who  dwell  in  crowded 
tenement-houses.  It  is  more  common  in  the  great  cities  of 
England  and  Europe  than  in  this  country.  Acute  disease  and 
troublesome  dentition  predispose  to  it.  It  is  more  apt  to  occur 
in  children  of  rachitic,  syphilitic  or  phthisical  parents.  The  off- 
sj>ring  of  consaiiguinious  marriages,  of  those  too  old,  or  of  the 
feeble  and  cachectic,  are,  as  a  rule,  rickety.  The  rickety  consti- 
tution may  also  be  inherited.  Of  the  exciting  causes,  the  most 
common  is  the  use  of  food  not  sufficiently  nutritive,  or,  if  nutri- 
tious, not  suited  to  the  age  and  digestive  powers  of  the  child. 
Thin  and  poor  breast-milk  and  artificial  food  of  poor  quality  are 


476  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

common  causes  of  rickets.  The  presence  of  lactic  acid  in  the 
intestinal  canal  of  the  infant  may  produce  rickets  according  to 
some  authorities.  The  disease  is  rare  before  the  fourth  and  after 
the  seventh  year  of  life.  Children  of  well-to-do  families  are  also 
liable  to  rickets  (Bartholow,  Loomis  and  J.  L.  Smith). 

Symptoms. — Usually  gastro- intestinal  disturbances  are  the 
earliest  symptoms  of  rickets.  There  may  be  vomiting,  and  the 
stools  are  frequent,  pasty  and  offensive.  The  stools  are  light  in 
color,  because  of  the  absence  of  bile,  and  have  an  acid  reaction. 
The  appetite  is  poor.  The  child  wastes  and  grows  dull,  listless 
and  peevish.  Pains  about  the  joints  are  complained  of.  The 
anterior  fontanelle  remains  open. 

Profuse  perspirations  of  the  head,  neck,  and  upper  part  of 
the  chest,  appear  chiefly  while  the  child  is  asleep,  but  at  the  same 
time  the  abdomen  and  extremities  are  dry  and  hot.  The  child 
kicks  off  the  covers  from  its  legs.  There  seems  to  be  tenderness 
of  the  whole  body,  and  the  rickety  child  cries  out  when  it  is 
taken  up,  or  moved,  or  pressed  on.  It  is  languid,  its  counten- 
ance wearied,  depressed,  and  aged,  the  face  grows  broad  and 
square,  the  hair  is  thin,  dry,  and  dead,  the  muscles  are  wasted, 
and  flabby,  the  head  sinks  between  the  shoulders,  and  the  abdo- 
men is  swollen  and  protuberant.  Now  the  extremities  of  the  long 
bones  swell  and  have  a  knobby  appearance,  and  the  bone  bends 
readily.  The  child  may  be  knock-kneed,  or  have  bow-legs. 
Curvature  of  the  spine  also  takes  place.  The  lower  jaw  is  short- 
ened, so  that  the  upper  teeth  overlap  the  lower.  The  teeth  appear' 
late.  Rachitic  children  are  usually  pigeon-breasted,  and  there  is 
often  marked  deformity  of  the  pelvis.  The  ribs,  being  softened, 
yield  to  the  atmospheric  pressure,  thus  projecting  the  sternum 
forward.  The  head  of  a  rickety  child  appears  larger  than  that  of 
a  healthy  child  of  the  same  age,  is  flat  on  top,  and  the  forehead 
is  large  and  square.  The  limbs  of  the  child  are  short  in  propor- 
tion to  the  trunk.  Rachitic  children  are  anaemic  and  very  sensi- 
tive to  changes  of  temperature.  As  the  osseous  changes  go  on 
emaciation  goes  on  at  the  same  rate,  the  abdomen  enlarges  still 
more,  the  muscles  waste  and  grow  weaker,  there  is  less  and  less 
disposition  to  voluntary  exertion,  the  perspirations  are  more  free, 
the  thirst  increases,  the  bowels  become  more  deranged,  the  stools 


RACHITIS.  477 

fetid,  and  the  food  passes  unchanged.  All  rickety  children  do  not 
emaciate.  Persons  who  were  rachitic  in  infancy  frequently  be- 
come very  strong  as  they  reach  adult  life  (Bartholow,  Loomis 
and  J.  L.  Smith), 

Differential  Diagnosis. — The  only  disease  with  which  rickets 
in  its  early  stage  may  be  confounded  is  inherited  syphilis. 
Rickets  does  not  appear,  as  does  syphilis,  during  the  first  days 
of  life.  The  "snuffles"  and  cutaneous  lesions  do  not  belong  to 
rickets;  the  sweats  about  the  head,  the  osseous  changes,  the 
enlargement  of  the  spleen  and  liver,  the  weakness  of  the  legs, 
the  rims  around  the  cranial  bones,  the  large,  lax  joints,  and  the 
gastro-intestinal  disturbances  are  symptoms  of  rickets  which  dis- 
tinguish it  from  any  other  disease  (Bartholow  and  Loomis). 

Prognosis. — Is  usually  favorable,  provided  no  serious  com- 
plication arises.  The  complications  of  rickets  are  bronchitis, 
pneumonia,  enteritis,  laryngismus  stridulus,  convulsions,  difficult 
dentition,  diarrhoea,  and  chronic  hydrocephalus  (Loomis). 

Treatment. — Good  air,  warm  clothing,  daily  bathing,  and  a 
nutritious  diet  are  essential.  Children  kept  too  long  at  the 
breast  often  become  rickety,  and  should  be  weaned  at  once. 
Good  cow's  milk,  diluted  by  one-third  to  one-fourth  of  lime- 
water  is  the  most  suitable  aliment.  Scraped  raw  beef,  with  a 
small  amount  of  wine,  often  produces  marked  improvement. 
Pepsin  with  bismuth  may  be  given  for  the  vomiting  and  diar- 
rhoea. Pepsin  with  diluted  muriatic  acid  is  also  useful.  Cod- 
liver  oil  should  be  taken  as  early  and  in  as  large  doses  as  the 
child  can  digest.  Beef  tea  may  be  given.  Rachitic  children 
should  not  sleep  on  feather  beds  or  high  pillows.  The  perspira- 
tions may  be  relieved  by  sponging  with  vinegar  and  water.  The 
following  formula  will  be  found  useful  in  most  cases: 

|fc     Olei  morrhme 3iv. 

Aqua;  calcis 

Syrupi  calcis  lactophosphatis — aaoij. — M. 

Of  this,  one  teaspoonful  should  be  given  four  or  five  times 
daily  to  an  infant  of  one  year  (Bartholow,  Loomis  aud  J.  L. 
Smith). 


478  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

RHEUMATISM. 

Is  a  constitutional  disease  characterized  by  certain  local 
manifestations  seated  in  the  articulations  and  the  fibrous  tissues 
in  other  parts  (Flint). 

Varieties. — I.  Acute  articular  rheumatism.  II.  Sub- acute 
articular  rheumatism.  III.  Chronic  articular  rheumatism.  IV. 
Arthritis  deformans.  V.  Muscular  rheumatism,  "  Myalgia " 
(Loomis).  Acute  articular  rheumatism  frequently  called  rheu- 
matic fever  and. polyarthritis  rheumatica  is  the  variety  charac- 
terized by  fever,  inflammation  of  the  joints  occurring  in  succes- 
sion and  by  a  tendency  to  attack  the  peri-  and  endocardium. 

Causes. — It  is  more  frequent  in  men  than  in  women  because 
men  are  more  exposed  to  the  influences  producing  it.  Protracted 
stay  in  damp  apartments,  lying  between  damp  sheets  all  night, 
exposure  of  the  body  to  cold  and  wet,  when  in  a  heated  and  per- 
spiring state  act  only  as  an  exciting  cause.  A  special  predisposi- 
tion is  requisite.  This  predisposition  or  diathesis  may  be  con- 
genital and  inherited  or  it  maybe  acquired.  There  is  an  hered- 
itary tendency  in  about  thirty  per  cent,  of  cases.  It  occurs 
mostly  between  fifteen  and  thirty  years  of  age.  It  is  rare  in  old 
age.  The  seasons  of  greatest  prevalence  are  winter  and  spring. 
Some  claim  that  an  excess  of  sulphur  or  lactic  acid  in  the  blood 
will  produce  rheumatism  if  the  vice  of  constitution  exists.  Erysip- 
elas, dysentery,  scarlatina,  gonorrhoea,  syphilis,  pregnancy,  scrof- 
ula, phthisis  and  cancerous  affections  seem  to  act  as  exciting 
causes  (Bartholow,  Flint  and  Loomis). 

Symptoms. — In  the  majority  of  cases,  acute  articular  rheuma- 
tism begins  with  a  sudden  attack  at  night.  In  some  cases  the 
pyrexia  precedes  the  local  manifestations  for  a  few  hours  to  one 
or  two  days.  Before  the  attack  patients  often  complain  of  mus- 
cular soreness,  of  a  good  deal  of  pain,  stiffness  and  soreness  of 
certain  joints,  of  loss  of  appetite,  coated  tongue  and  constipa- 
tion. The  development  of  the  disease  is  denoted  by  an  affection 
of  one  or  more  of  the  larger  joints.  The  local  symptoms  are 
pain,  tenderness,  increased  heat,  swelling,  and  redness  of  the 
skin.  Pain  is  especially  excited  by  movements  of  the  affected 
joints,  or  by  jarring  the   bed,  or  by  pressure   over  the   joints. 


RHEUMATISM.  479 

Swelling  is  most  apparent  in  the  knee,  wrist,  elbow,  ankle,  and 
smaller  joints  of  the  hands  and  feet,  and  is  due  to  an  effusion 
into  the  synovial  cavity  and  surrounding  tissues.  The  redness  is 
due  to  an  erythema.  In  some  cases  several  joints  are  affected, 
but  in  other  cases  a  single  joint.  The  most  characteristic  feature 
of  acute  rheumatism  is  its  tendency  to  migrate  from  one  joint  to 
another.  Rheumatism  illustrates  the  law  of  parallelism  in  that 
corresponding  joints  are  often  affected  together.  In  an  analysis 
of  21  cases,  Flint  found  but  a  single  violation  of  this  law.  This 
disease,  therefore,  is  eminently  one  of  the  bilateral  or  symmetri- 
cal diseases.  The  joints  most  frequently  affected  are  the  aukle 
and  knee;  next  the  shoulder,  elbow  and  wrist;  then  the  hip  and 
fingers,  and  finally  the  spine,  the  toes  and  the  lower  jaw.  Acute 
articular  rheumatism  is  always  accompanied  by  more  or  less 
pyrexia.  The  axillary  temperature  in  different  cases  varies  be- 
tween 102°  and  110°  F.  The  pulse  rarely  exceeds  100  per 
minute.  Sweating  is  a  symptom  more  or  less  prominent,  occur- 
ring especially  at  night.  The  sweat  emits  a  notably  sour  odor. 
In  connection  with  profuse  sweating,  sudamina  or  miliary  vesicles 
frequently  appear  on  the  neck  and  trunk.  Urticaria,  erythema 
aud  herpes  labialis  sometimes  occur  in  the  course  of  the  disease. 
The  appetite  is  lost,  thirst  is  urgent,  the  tongue  is  coated,  the 
saliva  is  acid,  usually  the  bowels  are  constipated,  and  the  urine 
is  diminished.  There  is  sleeplessness.  Endocarditis  occurs  in 
some  cases  of  rheumatism.  The  inflammation,  as  a  rule,  affects 
the  membrane  situated  upon  the  mitral  valve.  Pericarditis  occurs 
less  frequently.  It  is  convenient  to  speak  of  these  affections  as 
complications,  but,  properly  speaking,  they  are  to  be  reckoned 
among  the  local  manifestations  of  the  disease.  They  rarely  occur 
in  patients  beyond  forty.  Other  rare  complications  are  purulent 
meningitis,  cerebral  embolism,  uraemia,  insauity,  bronchitis, 
pneumonia,  peritonitis,  nephritis,  myocarditis,  phlebitis,  suppur- 
ative arthritis,  erysipelas  and  pyaemia.  In  a  small  number  of 
cases  of  acute  rheumatism,  important  symptoms  develop  which 
are  described  under  the  names  of  cerebral  rheumatism  and  rheu- 
matic hyperpyrexia.  In  these  cases,  there  are  very  high  fever, 
delirium,  muscular  twitchings,  stupor,  face  cyanosed,  etc.  These 
symptoms  seem  to  be  referable  to  some  profound  infection  or  in- 


480  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

toxication  which,  acts  upon  the  thermic  and  other  nervous  cen- 
tres. The  disease  ends  by  self -limitation.  The  duration  of  acute 
articular  rheumatism  is  three  weeks  to  thirty  days  (Bartholow, 
Flint  and  Loomis). 

Differential  Diagnosis. — Acute  rheumatism  may  be  mistaken 
for  gout,  pycemia,  synovitis,  or  simple  acute  arthritis,  urethral 
rheumatism,  and  hysterical  joint.  Gout  attacks  the  small  and 
rheumatism  the  large  joints.  In  gout  the  fever  is  lower,  and  the 
duration  of  the  attack  shorter  than  in  rheumatism.  Sweats  and 
cardiac  mischief  distinguish  rheumatism  from  gout.  In  gout  the 
attack  comes  on  at  night  in  the  great  toe  joint;  there  is  a  history 
of  high  living,  and  an  excess  of  uric  acid  in  the  blood;  not  so  in 
rheumatism.  Gout  is  rare  before  thirty-five,  while  acute  rheu- 
matism is  a  disease  of  early  adult  life.  Tophi  never  form  in 
rheumatism,  but  are  always  present  late  in  gout.  In  pyamiia 
there  are  recurring  chills,  sickly,  sweet  breath,  slow  development, 
jaundice,  multiple  abscesses,  etc.  Synovitis  or  acute  arthritis  is 
distinguished  by  its  persistence  in  one  joint,  by  the  absence  of 
sweats,  of  constitutional  disturbance  and  of  cardiac  lesions,  and 
by  the  graver  local  symptoms.  Urethral  or  gonorrhoea}  rheuma- 
tism attacks  one  joint,  usually  the  ankle  or  wrist,  does  not  mi- 
grate, is  slower  to  recover,  is  unaccompanied  by  fever,  and  is 
coincident  with  a  urethral  discharge.  Hysterical  joint  is  without 
swelling  or  change  of  temperature,  and  is  only  sensitive  when  the 
patient's  attention  is  fixed  on  it  (Bartholow,  Flint  and  Loomis). 

Prognosis. — This  disease  is  rarely  fatal.  The  rule  is  that  no 
crippling  of  the  joints  follows  the  acute  attack.  The  worst 
legacy  acute  rheumatism  leaves  is  a  crippled  valvular  apparatus 
in  the  heart.  Some  authorities  say  that  seventy-five  pei  cent,  of 
all  cases  of  rheumatic  fever  are  accompanied  by  cardiac  inflam- 
mations, others  say  five  per  cent.  The  complications — pericar- 
ditis, endocarditis  and  embolism  make  the  disease  serious.  Ul- 
cerative endocarditis  is  a  grave  sequel  of  the  disease,  giving  rise 
to  fatal  pysemia.  A  strange  sequel  of  rheumatic  fever  is  chorea 
(Flint  and  Loomis). 

Treatment. — Rheumatic  patients  should  have  good  hygienic 
surroundings.  The  temperature  of  the  apartment  should  range 
from  68°  to  70°  F.;    all  draughts   should  be  avoided,   and  the 


RHEUMATISM.  481 

patient  should  be  clothed  in  flannel  and  covered  with  flannel 
sheets.  The  diet  should  be  milk  and  seltzer-water,  beef-tea  and 
broths.  Animal  food  and  alcoholic  stimulants  should  not  be 
given  during  the  active  period  of  the  disease. 

External  Applications. — Cold,  by  means  of  ice-bags  to  the 
joints,  has  been  strongly  recommended.  Friction  with  chloro- 
form and  the  tincture  of  aconite  is  a  favorite  plan  with  some. 
"Hot-packs"  by  means  of  flannel,  or  bathing  the  joints  in  warm 
laudanum  and  then  covering  them  with  oiled  silk,  is  always 
grateful  to  the  patient.  Ethyl  chloride  or  ether  may  be  rubbed 
over  the  affected  joints.  Loomis  is  of  the  opinion  that  the  blis- 
ter-treatment is  no  better  than  simply  surrounding  the  joints  with 
cotton -batting  and  oiled  silk.  But  Dr.  Greenhow  finds  that  the 
blister-treatment  is  quite  as  successful  as  the  treatment  by  sali- 
cylates, and  open  to  less  objection.  The  blistering- plaster  should 
be  applied  about  the  inflamed  joint,  but  not  on  it.  Blisters  re- 
lieve the  pain  remarkably,  change  the  reaction  of  the  urine  from 
acid  to  neutral  or  alkaline,  and  prevent  complications.  Blisters 
may  be  utilized  in  all  forms  of  the  disease  and  combined  with 
other  plans  of  treatment. 

Internal  Medication. — Kheumatism  is  the  most  unmanageable 
of  all  diseases  so  far  as  remedies  are  concerned.  Garrod  thinks 
colored  water  is  about  as  potent  as  anything.  He  claims  that 
rheumatic  fever  is  a  self-limited  disease.  The  alkaline  treatment 
is  the  treatment  in  which  alkalies  play  an  important  part.  Two 
drachms  of  the  bicarbonate  of  either  potassium  or  sodium  may 
be  given  in  a  state  of  effervescence  by  means  of  an  ounce  of 
lemon  juice,  or  a  half  drachm  of  citric  acid  in  four  ounces  of 
water  every  three  or  four  hours.  If  the  urine  is  alkaline  at  the 
end  of  twenty -four  hours  the  quantity  of  alkali  is  diminished 
one -half.  If  the  urine  continues  alkaline  at  the  end  of  forty - 
eight  hours,  three  drachms  of  alkali  only  are  given  on  the  third 
day.  If  the  alkalinity  of  the  urine  persists,  on  the  fourth  day 
three  grains  of  quinine  with  a  half  drachm  of  potassium  bi- 
carbonate may  be  given  three  times  daily.  Cathartics  may  be 
given  as  required.  The  alkaline  treatment  relieves  the  pain,  seems 
to  shorten  the  duration,  lessens  the  violence  of  the  disease  and 
prevents  heart  complications.  The  average  duration  of  the  cases 


482  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

thus  treated  is  put  by  Dr.  Fuller  at  eleven  clays.  Of  439  cases 
subjected  to  this  plan  there  was  not  a  fatal  case,  and  only  about 
two  per  cent,  of  cardiac  complications.  Loomis  thinks  that  if 
long  continued  the  alkalies  do  positive  harm.  The  alkaline  treat- 
ment is  particularly  applicable  to  the  obese,  florid,  but  flabby 
drinkers  of  malt  liquors.  The  iron  treatments  applicable  to  the 
pale,  delicate  anaemic  young  subject  attacked  with  acute  rheu- 
matism, in  whom  the  alkalies  are  too  depressing.  A  half  drachm 
of  the  tincture  of  the  chloride  of  iron  to  six  ounces  of  water,  may 
be  taken  through  a  glass  tube  every  four  hours. 

The  salicylic  or  salicylate  treatment  is  most  applicable  to  the 
vigorous,  able-bodied  subjects  of  the  rheumatic  diathesis.  Sali- 
cin,  salicylate  of  soda  and  salicylic  acid,  to  be  effective,  must  be 
given  in  sufficient  quantity  to  lower  the  temperature — a  half- 
drachm  of  salicylate  of  sodium  every  four  hours,  until  the  pulse 
and  temperature  decline,  may  be  taken  as  the  standard.  Al- 
though relief  follows  the  administration  of  these  remedies  in 
two  or  three  days,  yet  the  tendency  to  relapses,  heart  depression 
and  irritability  of  the  stomach  is  very  great.  The  salicylate 
treatment  does  not  prevent  the  heart  complications.  The  best 
results  are  obtained  by  the  combination  of  the  salicylate  and  the 
alkaline  treatment.  Loomis  prefers  salol  to  salicylic  acid.  He 
seldom  uses  the  alkaline,  or  salicylate  treatment,  but  extols  anti- 
pyrine  as  the  most  efficient  drug.  Flint  gives  antipyrine  in 
fifteen  grain  closes  hourly,  but  does  not  give  more  than  two 
drachms  in  twenty-four  hours.  For  the  intense  hyperpyrexia  in 
some  cases,  large  doses  of  quinine  may  be  given  and  cold  spong- 
ing practiced.  Dr.  Kinnicutt  gives  10  to  15  minims  of  the  oil  of 
winter  green  every  two  hours  until  eight  doses  have  been  taken. 
DaCosta  has  reported  30  cases  treated  with  the  bromide  of  am- 
monium in  doses  of  15  to  20  grains  every  three  hours  (Bartho- 
low,  Flint  and  Loomis). 

Subacute  Articular  Rheumatism. — Is  usually  a  sequel  of  the 
acute;  it  is  attended  by  slight  if  any  fever;  the  pain  in  joints  is 
not  severe,  except  on  motion;  swelling  and  redness  are  slight 
and  usually  limited  to  one  or  two  large  joints.  It  may  last  six 
weeks   or   even  four  months.     There  is   always   anaemia.     The 


RHEUMATISM.  483 

treatment  is  a  milk  diet,  iron  and  cod -liver  oil,  a  warm  climate, 
and  heat  to  the  affected  joints  (Loomis). 

CHRONIC  ARTICULAR  RHEUMATISM. 

Is  an  affection  of  the  articulations  characterized  by  pain  and 
stiffness,  with  some  swelling,  occurring  chiefly  after  middle  life, 
and  influenced  by  atmospheric  changes  (Bartholow). 

Causes. — The  chronic  may  succeed  to  the  acute,  or  the  case 
may  be  chronic  from  the  first.  It  is  a  disease  of  adult  and  ad- 
vanced life.  Bad  hygienic  surroundings,  exposure  to  wet  and 
cold,  sudden  atmospherical  changes,  and  a  residence  in  dark  and 
damp  dwellings  predispose  to  it.  It  is  often  hereditary  (Bartho- 
low and  Loomis). 

Symptoms. — The  affection  remains  fixed  in  certain  joints; 
that  is,  it  does  not  shift  from  joint  to  joint,  as  in  cases  of  acute 
rheumatism.  There  is  aching  and  constant  pain  in  one  or  more 
of  the  larger  joints.  The  affected  joints  are  tender,  painful  to 
the  touch,  sometimes  swollen,  and  their  movements  restrained. 
There  is  no  fever.  The  aching  and  deep-seated  pains  are  often 
worse  at  night.  When  it  is  the  result  of  exposure,  heat  will  give 
a  grateful  sense  of  relief;  when  a  rheumatic  diathesis  exists,  dry 
cold  is  better.  Old  people  with  rheumatic  joints  are  great 
u weather  prophets"  often  being  able  to  foretell  the  coming  of  a 
storm.  In  the  morning,  on  rising,  the  joints  are  stiff,  their 
movements  slow,  rigid  and  jerking,  so  that  dressing  is  accomp- 
lished with  difficulty;  but  use  renders  them  limber  and  supple. 
Movements  of  the  joints  may  cause  more  or  less  creaking  like 
rusty  machinery  (Bartholow,  Flint  and  Loomis). 

Differential  Diagnosis. — Chronic  rheumatism  may  be  mistaken 
for  rheumatoid  arthritis,  or  arthritis  deformans.  In  the  latter 
occur  anatomical  changes,  dislocations,  and  distortions  which  do 
not  belong  to  the  history  of  chronic  rheumatism.  Arthritis  de- 
formans is  a  steadily  progressive  disease,  one  joint  after  another 
being  involved  and  never  recovered  from.  In  chronic  rheuma- 
tism the  large  joints  are  mainly  involved;  in  arthritis  the  small 
joints  are  usually  first  involved,  then  the  large  (Loomis). 

Prognosis. — -Chronic  rheumatism  never  affects  the  duration 
of  life.     It  may  persist  throughout  life  (  Loomis  ). 


484  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Treatment. — Chronic  rheumatism  is  benefited  most  by  local 
treatment,  such  as  blisters,  iodine,  belladonna,  acpnite,  opium 
and  chloroform  liniments.  If  there  is  but  little  pain  in  the 
joints,  ammonia  and  turpentine  liniments  are  of  service.  Thick 
flannels  should  always  be  worn  about  the  joints.  Sponging  the 
joints  with  hot  water  will  relieve  the  pain  and  stiffness  in  some 
cases.  Warm  baths,  the  Turkish  or  Russian  baths,  with  local 
douches,  are  often  highly  useful.  Many  of  the  hot  saline  springs 
for  bathing  have  acquired  a  great  reputation  in  the  treatment  of 
this  form  of  rheumatism,  cures  being  effected  in  cases  that  had 
resisted  all  other  methods  of  treatment.  The  best  results  are 
obtained  from  the  baths  of  the  Hot  Springs  of  Arkansas,  the 
warm  and  hot  springs  of  Virginia,  the  sulphurous  waters  of 
Kentucky  and  Saratoga,  the  Michigan  springs,  and  St.  Cather- 
ine's of  Canada.  Mud-baths  are  also  employed  on  a  large  scale, 
for  the  relief  of  rheumatism  and  affections  of  the  skin,  in  certain 
parts  of  Germany.  Frictions  of  the  affected  parts  with  cod-liver 
oil  are  efficacious.  The  method  of  friction  and  movements, 
Tvnown  as  massage,  is  probably  the  best  of  the  local  means  of 
treatment.  Galvanism  has  been  found  serviceable.  The  posi- 
tive pole  should  be  placed  over  the  principal  nerve-bundles 
above,  and  the  negative  pole  brushed  over  the  joint-region.  The 
.electrical  treatment  must  be  kept  up  for  a  long  time. 

Internal  Medication.- — Tonics  such  as  iron,  quinine,  and 
strychnine  should  be  employed.  Cod-liver  oil,  according  to 
Loomis,  is  the  most  useful  of  all  internal  remedies,  and  should 
be  given  for  many  months.  Cod-liver  oil  should  be  given  with 
a  little  ether  to  assist  its  digestion.  A  course  of  iodide  of  potas- 
sium often  renders  important  service,  if  given  many  months. 
Muriate  of  ammonia  may  absorb  deposits  about  the  joints  but  it 
must  be  given  for  a  long  time.  Bartholow  has  had  excellent  re- 
sults from  the  bromide  of  lithium.  Colchicum,  arsenic,  bichlor- 
ide of  mercury,  guaiacum,  oils  of  turpentine  and  cajeput,  com- 
bined with  sulphur  have  been  recommended.  The  diet  must  be 
highly  nutritious  and  absolutely  non- stimulating.  The  patient 
should  reside  in  a  dry,  warm  climate  (Bartholow,  Flint  and 
Loomis). 


RHEUMATOID    ARTHRITIS.  485 

RHEUMATOID  ARTHRITIS, 

Called  also  arthritis  deformans,  rheumatic  gout,  rheumatic 
aHhritis,  nodosity  of  the  joints,  dry  arthritis,  etc.,  is  a  chronic 
inflammation  of  the  joints,  without  fever  and  without  suppura- 
tion, progressive,  and  causing  enlargement  and  deformity  of 
various  articulations  (Bartholow). 

Causes. — It  may  occur  at  any  age,  but  in  the  majority  of 
cases  patients  are  in  middle  life.  Women  are  more  liable  to  it 
than  men.  The  smaller  joints  are  most  often  involved  in  women; 
the  larger  in  men.  Damp  dwellings,  poor  food,  and  mental  de- 
pression are  powerful  predisposing  causes.  It  is  not  an  inherited 
disease.  It  occurs  in  the  poorer  classes  of  society,  as  a  rule,  and 
among  those  who  suffer  from  hardships,  exposure,  and  depriva- 
tions. Garrod  holds  that  it  may  have  its  origin  in  the  tubercular 
diathesis.  A  state  of  the  nerve-centres  is  invoked  to  account  for 
this  disease  (Bartholow,  Flint  and  Loomis). 

Symptoms. — The  disease  is  usually  from  the  first  and  during 
its  course,  sub-acute.  A  feature  of  the  disease  is  its  progressive 
character.  There  is  usually  no  constitutional  disturbance.  The 
affected  joints  are  painful,  especially  on  motion.  A  characteris- 
tic deformity  of  the  fingers  is  a  lateral  deflection  in  the  ulnar 
direction.  In  the  progress  of  the  disease  the  anatomical  changes 
lead  to  permanent  extension  or  flexion  of  parts,  subluxations, 
dislocations,  nodulations  and  notable  distortions.  The  soft  parts 
about  the  joints  usually  atrophy.  Early  in  the  disease  a  friction 
crepitus  is  heard  as  the  articular  surfaces  are  rubbed  upon  each 
other.  The  skin  is  dry  and  harsh,  and  there  is  a  great  acidity  of 
the  stomach.  In  the  worst  cases  all  the  joints  are  fixed  in  bony 
ankylosis  (Bartholow,  Flint  and  Loomis). 

Differential  Diagnosis. — Arthritis  deformansm&y  be  confound- 
ed with  chronic  rheumatism  and  chronic  gout.  Gout  is  hered- 
itary and  occurs  more  in  males.  Arthritis  deformans  is  rarely 
hereditary  and  occurs  oftenest  in  females.  Attacks  of  gout  are 
periodic.  Arthritis  is  progressive.  Chalk-stones  develop  in  the 
joints  in  gout  and  are  never  present  in  arthritis.  Uric  acid  is  al- 
ways in  excess  in  gout,  and  never  in  arthritis  (Loomis). 

Prognosis. — It  is  one  of  the  most  chronic  of  diseases.  It  may 
continue  for  ten,  twenty  or  thirty  years   or  longer.     It  never  de- 


486  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

stroys  life,  and  is  never  recovered  from.     Patients  with  this  dis- 
ease may  attain  very  old  age  (Bartholow  and  Loomis). 

Treatment. — Quinine,  iron,  cod-liver  oil,  arsenic  and.  strych- 
nine are  indicated.  Flannels  should  always  be  worn  next  the 
shin.  Mineral  waters  and  warm  saline  baths  often  do  good. 
Bartholow  recommends  iodine  and  galvanism.  He  gives  five 
minims  of  the  compound  solution  three  times  daily.  Iodine  oint- 
ment may  be  rubbed  into  the  affected  joints.  The  galvanic  cur- 
rent is  often  of  great  benefit  (Bartholow  and  Loomis). 

RANULA. 

Is  a  sublingual  cyst. 

Cause. — Ranula  is  caused  by  an  obstruction  of  one  of  the 
mucous  glands  situated  beneath  the  tongue.  They  were  once 
thought  to  be  clue  to  an  obstruction  of  the  salivary  ducts.  They 
are  analogous  to  the  mucous  cysts  of  the  lip.  They  contain  a 
clear,  glairy,  mucoid  fluid.  They  may  be  congenital.  They 
may  form  a  large  swelling  beneath  the  jaw.  When  large  they 
press  the  tongue  upward.  They  are,  as  a  rule,  painless,  and 
merely  give  trouble  by  pressure  (Bryant). 

Treatment. — The  best  treatment  is  to  raise  the  upper  wall 
of  the  cyst  by  means  of  a  pair  of  pointed  forceps,  or  a  tenaculum, 
and  with  scissors  to  cut  it  off.  Panas,  of  Paris,  has  lately  in- 
jected these  cysts  with  three  to  ten  drops  of  a  solution  of  chlo- 
ride of  zinc  (forty-five  grains  to  the  ounce)  with  success.  In 
large  tumors  the  cavity  may  be  plugged  with  lint  soaked  in 
iodine,  or  with  iodoform  gauze,  after  it  has  been  freely  incised. 

Encysted  tumors  are  also  met  with  beneath  the  tongue,  and 
may  be  mistaken  for  ranula;  but  these  tumors  have  a  distinct 
capsule  and  contain  a  cheesy,  sebaceous  secretion.  They  are 
probably  congenital  (Bryant). 

RETENTION  OF  URINE. 

When  a  patient  is  unable  to  pass  his  urine,  he  is  said  to  have 
retention.  When  no  urine  comes  down  from  the  kidneys,  he  is 
said  to  have  suppression  (Keyes). 

Causes. — Stricture  (organic  or  spasmodic),  enlarged  pros- 
tate, inflammation  or  acute  congestion  of  the  prostate,  spasm  of 


RANT LA RETENTION    OF    URINE.  487 

the  cut-off  muscles,  true  vesical  paralysis,  urethral  calculus  aucl 
inflammation  of  the  urethra  are  capable  of  producing  retention. 
Voluntary  retention,  often  repeated  and  long  kept  up,  may 
result  in  retention.  Blunted  sensibility  of  the  bladder  in  typhus, 
small -pox,  coma,  in  some  syphilitic  and  inflammatory  brain 
diseases,  in  shock  from  injuries,  and  in  all  conditions  of  spasm  of 
the  deep  urethral  muscles,  are  causes.  Excess  of  drinking,  with 
or  without  exposure  to  wet  and  cold,  is  an  exciting  cause.  Re- 
tention in  a  child  is  generally  from  stone  impacted  in  the 
urethra;  in  an  adult  from  stricture;  and  in  an  old  man  from 
prostatic  disease  (Keyes). 

Symptoms. — The  bladder  may  be  often  seen  and  felt,  filling 
up  the  hypogastrium,  perhaps  reaching  the  navel.  Pressure 
upon  it  usually  causes  a  desire  to  urinate.  Fluctuation  may  be 
made  out  between  a  finger  in  the  rectum  and  the  hand  upon  the 
hypogastric  tumor.  In  retention  there  is  always  flatness  over  the 
pubes  (Keyes). 

Treatment. — In  retention  from  atony,  paralysis,  fever,  etc., 
a  soft  catheter  of  medium  size  should  be  passed  as  often  as  re- 
quired and  the  bladder  should  be  washed  out  on  each  occasion 
with  a  hot  solution  of  borax  in  water.  A  piece  of  ice  about  the 
size  of  a  chestnut  introduced  into  the  rectum  may  relieve  reten- 
tion. In  retention  from  spasmodic  st/ricture  caused  by  exposure 
to  wet  or  cold  and  excess  of  drinking,  the  simple  passage  of  a 
large  metallic  catheter  well  warmed  and  oiled  is  indicated.  If 
the  instrument  will  not  pass  no  force  should  be  employed,  but  an 
anaesthetic  should  be  given  and  then  it  may  pass.  The  old  rem- 
edy of  a  hot  bath  cannot  be  too  highly  extolled  in  retention.  A. 
full  opiate  is  also  an  invaluable  remedy  relieving  the  involuntary 
contraction  of  the  bladder  and  the  pain.  In  retention  from  in- 
flammatory stricPwre  caused  by  gonorrhoea,  the  passage  of  a  small 
catheter,  or  a  hot  bath  and  a  full  opiate  are  the  best  remedies. 
In  retention  from  a  blow  in  the  perinceum,  the  simple  passage  of 
a  catheter  will  usually  suffice.  In  retention  f rom  pr essw6  of  an 
abscess  in  the  perinceum,  the  treatment  is  to  open  the  abscess 
(Keyes  and  Bryant). 


488  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ROSEOLA. 

Is  a  self-limited  eruptive  disease  pursuing  a  course  similar 
to  measles.  It  is  also  called  rose-rash,  false  measles,  German 
measles,  rotheln,  etc.  Modern  German  authors  call  this  disease 
rubeola  (Bartholow). 

Causes. — Roseola  is  contagious  and  is  essentially  a  disease  of 
childhood.  The  causes  are  in  a  measure  obscure.  The  delicacy 
of  the  skin  in  infancy  and  the  active  cutaneous  circulation  no 
doubt  predispose  to  roseola  and  erythema.  Summer  weather 
with  the  derangements  of  the  system  which  it  produces  is  the 
most  frequent  cause  of  idiopathic  roseola  in  young  children 
Loomis  and  Smith). 

Symptoms. — Roseola  is  one  of  the  mildest  of  the  eruptive 
fevers.  The  eruption  consists  of  rose- colored  sj)ots,  varying  in 
size  from  a  pin's  head  to  a  large  pea,  slightly  elevated,  so  that 
when  the  hand  passes  over  the  surface  of  the  skin  it  feels  some- 
what rough.  Sometimes  these  spots  occasion  intense  itching, 
are  quite  distinctly  separated  by  healthy  skin,  and  disappear 
under  pressure.  The  eruption  is  frequently  the  first  symptom 
of  the  disease.  There  may  be  slight  soreness  of  the  throat  and 
mild  catarrh  of  the  air-passages.  The  eruption  usually  com- 
mences upon  or  about  the  neck  and  face.  It  bears  considerable 
resemblance  to  that  of  measles.  There  is  no  fever  in  a  majority 
of  the  cases.  The  whole  duration  of  the  eruption  is  from  two  to 
four  days.  There  is  a  symptomatic  roseola  which  appears  in  the 
course  of  various  acute  febrile  diseases  with  the  exception  of 
syphilis  (Bartholow,  Loomis  and  J.  L.  Smith). 

Prognosis. — Is  favorable. 

Treatment. — Regulate  the  diet  and  keep  the  patient  in- doors. 

RELAXED  UVULA  AND  PALATE. 

Treatment. — Tannic  acid  is  much  employed  in  relaxed  con- 
dition of  the  mouth  and  throat.  Elongated  and  relaxed  uvula, 
relaxed  palate,  and  follicular  pharyngitis  are  effectively  treated 
by  insufflation  of  tannin.  In  chronic  affections  of  the  larynx 
mucous  membrane,  and  of  the  vocal  cords,  no  inhalation  is  more 


RASHES RESTLESSNESS.  489 

frequently  serviceable  than  a  solution  of  tannin  (grs.  x.-xx.  to  §iv.) 
applied  by  means  of  the  handball  atomizer.  In  chronic  inflam- 
mation of  the  throat  when  the  mucous  membrane  is  relaxed, 
swollen,  granular-looking,  and  covered  with  mucous  or  pus,  a 
few  applications  of  glycerine  of  tannin  brace  up  the  tissues  and 
lessen  or  remove  the  hoarseness  (Bartholow  and  Ringer). 

RASHES.     (Medicinal). 

The  administration  of  certain  drugs  has  a' tendency  to  bring 
out  eruptions  which  are  likely  to  be  mistaken  for  diseases  of  the  skin. 
Some  persons  are  peculiarly  prone  to  them  and  we  know  not 
why.  Arsenic  produces  an  erythema  or  an  urticaria  in  some 
persons,  when  given  in  large  doses.  Belladonna  or  atropia  may 
produce  a  scarlet  rash.  Bromides  produce  a  rash  similar  to  acne 
when  given  for  some  time  in  full  doses.  Quinine  may  give  rise 
to  an  erythematous  eruption.  In  some  persons  quinine  produces 
large  patches  of  erythema,  and  always  excites  a  violent  urticaria. 
Chloral  hydrate  occasionally  gives  rise  to  a  rash  not  unlike  that 
of  scarlet  fever.  Copaiba  and  cubebs  produce  a  rash  in  some  per- 
sons. Iodine  and  the  iodides  given  for  some  time  will  produce  a 
rash.  Opium  and  morphia  may  produce  an  erythematous  or 
urticarial  rash  which  is  very  itchy.  Tar,  creosote,  carbolic, 
digitalis,  stramonium,  stry china,  or  salicylic  acid  occasionally 
produce  an  eruption  in  those  who  are  taking  them    (Anderson). 

RESTLESSNESS. 

Ringer  says,  that  in  several  cases,  he  has  seen  aconite  quiet 
the  distressing  restlessness  of  "fidgets,"  which  affects  men  as  well 
as  women,  and  has  known  a  few  drops  at  bed -time  calm  the 
patient  and  give  sound,  refreshing  sleep;  if  one  drop  is  insufficient, 
it  may  be  repeated  hourly  for  three  or  four  hours.  Sponging 
with  hot  water  will  often  induce  perspiration,  soothe  the  restless 
ness  of  convalescence,  and  induce  sleep  (Ringer). 


490  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

RELAPSING  FEVER. 

Called  also  febris  recurrens,  typhus  recurrens,  spirillum 
fever,  five-day  fever,  seven- clay  fever,  short  fever,  mild  yellow 
fever \,  famine  fever,  hunger-pest,  and  dynamic  fever,  is  an  acute, 
infectious,  febrile  disease,  self- limited,  and  characterized  by  the 
occurrence  of  a  febrile  paroxysm,  lasting  about  one  week,  suc- 
ceeded by  an  entire  intermission  of  four  or  five  days'  duration, 
which  is  in  turn  followed  by  a  relapse  like  the  first  seizure, 
although  shorter.  It  has  never  been  indigenous  in  this  country. 
It  is  by  no  means  a  new  form  of  disease.  Accounts  in  the  writ- 
ings of  Hippocrates  leave  no  doubt  but  it  prevailed  2,000  years 
ago  in  the  islands  off  Thrace.  It  has  prevailed  as  an  epidemic 
disease  in  most  of  the  countries  of  Northern  Europe.  In  1844 
there  were  fifteen  cases  of  relapsing  fever  in  Philadelphia.  The 
patients  were  Irish  immigrants,  all  coming  over  in  the  same 
vessel.  Dr.  Dubois  reported  a  few  cases  in  1848,  and  Dr.  Flint 
fifteen  cases  in  1850-51.  All  these  were  among  recent  Irish  im- 
migrants. It  prevailed  as  an  epidemic  in  New  York  City  in 
1872-3,  the  disease  having  been  imported  by  foreign  immigrants. 
In  1865  there  was  a  great  epidemic  in  St.  Petersburg.  The  name 
relapsing  fever  is  to  be  preferred  to  any  of  the  other  appella- 
tions, as  it  is  based  on  one  of  the  most  striking  of  the  peculiari- 
ties of  the  disease  (Bartholow,  Flint  and  Loomis). 

Morbid  Anatomy. — The  lesions  are  those  of  an  acute  infecti- 
ous disease.  The  spleen  is  enlarged,  due  to  congestion  and 
hyperplasia  of  its  lymphoid  elements.  The  liver  is  also  enlarged 
and  is  the  seat  of  parenchymatous  degeneration.  The  kidneys 
are  swollen.  The  mucous  membrane  of  the  intestine  is  inflamed. 
Petechise  of  the  skin  are  present  in  about  10  per  cent,  of  the 
cases.  The  myocardium  may  be  affected  with  a  fatty  degenera- 
tion almost  as  intense  as  that  in  phosphorus -poisoning.  The 
blood  is  dark  and  coagulates  imperfectly.  In  1873  Obermeier 
discovered  a  spiral -shaped  bacterium  in  the  blood  of  relapsing 
fever  patients.  This  parasite  has  been  found  in  the  blood  in  no 
other  disease  (Flint). 

Causes. — Relapsing  fever  is  a  distinctly  contagious  affection. 
The  poison  acquires  the  greater  activity  the  more  filthy,  crowded 


RELAPSING    FEVER.  491 

and  unhealthy  the  population  amid  which  it  prevails.  Articles 
of  clothing  will  retain  the  contagious  principle  for  a  long  time, 
and  those  who  have  been  in  the  presence  of  the  sick  can  convey 
the  poison  to  the  healthy  at  a  distance.  Drinking  water  may  be 
contaminated  and  spread  the  poison.  The  disease  attacks  by 
preference  the  young,  the  liability  lessening  after  thirty  and  ap- 
parently ceasing  after  fifty.  One  attack  does  not  afford  immun- 
ity against  subsequent  attacks.  The  natural  home  of  relapsing 
fever  is  Ireland.  The  period  of  incubation  ranges  between  five 
and  seven  days,  rarely  nine.  Facts  go  to  show  that  it  is  not  a 
highly  contagious  disease.  Considerable  exposure  is  generally 
necessary.  The  disease  is  not  likely  to  be  contracted  from  single 
patients  in  well  ventilated  rooms.  Destitution  and  deficient 
alimentation  are  auxiliary  causes.  That  the  contagium  is  con- 
tained in  the  blood  does  not  admit  of  doubt.  In  accordance  with 
the  germ  theory,  the  first  paroxysm  of  relapsing  fever  is  due  to 
a  brood  of  spirochetes.  Their  existence  terminates  in  about  a 
week,  as  a  rule,  and  the  first  febrile  paroxysm  then  ends.  The 
germs  remaining  in  the  body  give  rise  to  a  second  brood  and 
there  is  the  relapse  of  the  fever.  In  rare  instances  a  third  and  a 
fourth  brood  are  produced.  The  contagium  is  probably  contained 
in  the  breath  and  the  cutaneous  exhalations  (Bartholow,  Flint 
and  Loomis). 

Symptoms. — The  recurrence  of  the  paroxysm  of  fever,  or  the 
relapse,  is  the  distinctive  feature  of  this  disease.  The  attack  is 
sudden.  It  is  marked  by  a  distinct  chill  with  fever,  frontal  head- 
ache, vertigo,  pain  in  the  limbs,  joints  and  back  and  usually 
nausea  and  vomiting.  Sweats  may,  at  first,  follow  the  chills. 
The  vomit  consists  first  of  the  contents  of  the  stomach,  then  of  a 
yellowish  material  and  this  may  be  followed  by  black  vomit 
similar  to  that  of  yellow  fever.  The  temperature  usually  attains 
its  highest  point  within  the  first  twenty-four  hours — 104°  F.  to 
even  109°  F.;  and  the  pulse  reaches  140,  150,  or  even  160  beats 
per  minute.  The  cessation  of  the  fever  is  as  abrupt  as  its  invas- 
ion. The  duration  of  the  primary  paroxysm  in  the  majority  of 
cases  is  between  five  and  seven  days.  It  may  be  two  or  fourteen 
days.  The  average  duration  of  the  apyrexial  period  or  inter- 
mission is  about  seven  days.  The  relapse,  like  the  primary  attack, 


492  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  sudden,  with  chilly  sensations,  fever,  etc.  The  relapse  also 
ends  suddenly  with  profuse  sweat.  The  duration  of  the  relapse 
varies  between  three  and  five  days.  It  may  lie  one  or  ten  days. 
The  relapse  does  not  always  occur.  But  two,  three,  four,  and 
even  fine  relapses  have  been  observed.  The  duration  of  the 
second  intermission  is  eight  or  nine  days,  and  that  of  the  third 
paroxysm  about  three  days.  The  duration  of  the  disease  aver- 
ages about  twenty-five  days.  The  tongue  is  coated  and  soon 
becomes  very  dry  and  sore.  Herpes  labialis  may  occur.  Epistaxis 
is  frequent.  There  may  be  diarrhoea  or  constipation.  Meteorism 
is  common.  Tenderness  in  the  epigastric  and  iliac  regions  on 
pressure  is  common.  Jaundice  is  developed  in  some  cases.  A 
dirty,  yellowish  color  of  the  shin  is  present  in  most  cases. 

During  the  first  paroxysm,  pains  in  the  loins,  the  calves  of 
the  legs,  and  the  muscles  in  other  situations  are  generally  much 
complained  of.  They  are  never  wanting.  The  muscular  pains 
do  not  cease  with  the  ending  of  the  paroxysm,  but  continue  dur- 
ing the  intermission.  They  are  more  or  less  prominent  during 
the  relapse.  The  pains  are  sometimes  referred  to  the  bones.  The 
mind  is  clear.  The  perceptions  are  not  blunted  in  this  disease  as 
they  are  in  typhus  and  typhoid  fever.  There  is  no  coma- vigil,  no 
subsultus  and  no  carphologia.  There  is  no  characteristic  erup- 
tion. Sudamina  or  miliary  vesicles,  sometimes  are  observed 
when  profuse  perspiration  occurs.  The  face  is  more  or  less 
flushed  but  there  is  not  that  degree  of  capillary  congestion, 
marked  especially  on  the  cheeks  which  exists  in  typhoid  fever 
or  the  dingy  complexion  which  characterizes  typhus.  Relapsing 
fever,  when  it  attacks  pregnant  women,  always  leads  to  miscar- 
riage or  abortion.  The  patient  goes  on  from  day  to  day  gradually 
getting  worse;  the  fever  becomes  more  and  more  intense;  loss  of 
strength  and  emaciation  are  progressive  and  the  muscular  pains 
are  more  severe;  when  on  the  seventh  day  of  the  fever  a  remis- 
sion suddenly  occurs.  (Edema  of  the  feet  due  to  general  anaemia 
is  often  quite  marked  during  convalescence.  Recovery  is  tedious 
(Bartholow,  Flint  and  Loomis). 

Differential  Diagnosis. — Relapsing  fever  may  be  confounded 
with  typhus,  typhoid,  yellow  fever,  small -pox  and  measles.  In 
typhus,  the  dusky  face,  contracted  pupils,  absence  of  all    abdom- 


RELAPSING    FEVER SALIVATION.  493 

inal  pain,  peculiar  smell,  stupor,  apathy  of  mind,  and  the  path- 
ognomonic eruption  on  the  fifth  or  seventh  day  will  be  sufficient 
to  distinguish  it  from  relapsing.  In  typhoid  the  slow  invasion, 
the  "step-ladder"  rise  in  temperature,  the  eruption  and  the 
characteristic  diarrhoea  will  distinguish  it  from  relapsing.  In 
yellow  fever  the  pulse  is  rarely  over  110,  the  spleen  is  normal 
and  only  a  remission  occurs.  In  small-pox,  the  eruption  appears 
on  the  third  day.  In  measles  the  eruption  follows  a  common 
cold  in  the  head.  Of  course  the  prevalence  of  relapsing  fever 
will  assist  the  diagnosis  (Loomis). 

Prognosis. — Is  always  good.  About  three  per  cent,  of  the 
cases  die.     Sudden  syncope  is  the  greatest  clanger  (Loomis). 

Treatment. — Dr.  Rutty  stated  more  than  a  century  ago  that 
all  those  cases  of  relapsing  fever  which  were  abandoned  to  whey 
and  the  good  providence  of  God  recovered.  Loomis  would  give 
very  little  medicine  in  this  disease.  If  there  is  any  evidence  of 
heart- failure,  he  would  give  digitalis  and  stimulants,  with  milk 
diet  and  free  ventilation.  For  the  pains,  Bartholow  advises 
morphine  hypodermically;  and  for  the  nausea,  half  a  grain  of 
carbolic  acid  in  cherry-laurel  water.  Tonic  remedies  are 
indicated. 

SALIVATION. 

Is  harmful  and  should  not  be  aimed  at.  The  greatest  effect 
that  it  is  allowable  to  produce  by  mercury  is  to  "touch  the 
gums."  When  the  gums  are  touched  there  will  be  an  increased 
flow  of  saliva,  a  faint  coppery  taste  in  the  mouth,  and  some  ten- 
derness of  the  gums,  tongue  and  mouth  (Keyes). 

Causes. — The  cause  of  salivation  is  special  idiosyncrasy  with 
a  small  dose  of  mercury,  or  no  idiosyncrasy  with  large  doses.  A 
mouth  kept  dirty  or  containing  bad  teeth  is  more  apt  to  suffer. 
The  influence  of  cold  and  wet  during  a  mercurial  course  may 
produce  it  (Keyes). 

Symptoms. — In  salivation,  the  salivary  fluids  How  freely, 
sometimes  to  an  enormous  extent;  the  breath  is  fetid,  the  metal- 
lic taste  is  very  marked;  the  gnms  are  sore;  the  teeth  feel  too 
long  for  the  patient  to  shut  his  mouth;  the  tongue  swells,  show- 
ing marks  of  the  teeth,  and  the  lips  and  cheeks  may  also  become 


494  A   COMPENDIUM   OF   practical    medicine. 

tumefied.  Often  there  is  fever.  The  teeth  may  fall  out,  or 
portions  of  the  soft  or  bony  parts  necrose.  The  articulation  is 
indistinct  and  painful  and  deglutition  almost  impossible  (Keyes). 
Treatment. —  During  salivation,  or  any  sore  mouth  from 
mercury,  ten  to  twelve  grains  of  chlorate  of  potash  to. the  ounce 
of  water,  or  any  bland  fluid,  may  be  used  as  a  mouth  wash  and 
gargle.  At  least  one  drachm  of  chlorate  of  potash  should  be 
taken  by  the  stomach  daily.  A  mild  solution  of  carbolic  acid, 
or  of  permanganate  of  potash,,  should  be  occasionally  used  as  a 
gargle  where  there  is  great  fetor  of  the  breath.  The  free  use  of 
the  hot  bath  is  of  advantage,  and  a  mild  diuretic  may  be  given. 
A  little  tincture  of  belladonna  may  be  given  to  restrain  the  sali- 
vary flow.  Astringent  gargles,  Labarraque's  solution,  tincture 
of  myrrh,  hot  milk,  cold  tea  may  be  used  as  mouth -washes 
(Keyes).  Alcohol  diluted  with  water  may  be  used  as  an  astrin- 
gent gargle  in  salivation.  Bromide  of  potassium  checks  the 
salivation  sometimes  occurring  in  pregnancy.  A  gargle  of  two 
drachms  of  tincture  of  iodine  to  eight  ounces  of  water  has  been 
recommended  to  allay  mercurial  salivation  (Ringer). 

SATYRIASIS. 

Is  constant  desire  with  erection;  erotic  delirium.  It  is  also 
a  brain  disease.  Acton  mentions  the  case  of  an  old  man  who 
was  eminently  satyiiasic,  so  much  so  that  he  would  masturbate 
in  the  presence  of  ladies.  Dying,  a  tumor  of  the  size  of  a  split 
pea  was  found  in  the  pons  Varolii  (Keyes). 

SCABIES. 

Called  also  "the  itch"  is  a  highly  contagious  disease,  especi- 
ally in  persons  who  are  inattentive  to  cleanliness.  It  is  com- 
municated by  sleeping  with,  or  on  the  beds  of  those  who  are 
affected,  or  by  coming  much  in  contact  with  them  in  any  way. 
It  may  also  be  transmitted  from  the  domestic  animals,  such  as 
the  cat.  It  is  oftener  met  with  in  winter  than  in  summer 
(Anderson). 

Causes.— The  cause  of  uthe  itch"  is  an  animal  parasite, 
called  cccarus  scahiei.     This  burrows  into  the  skin  particularly 


SCABIES SCARLET    FEVER.  495 

"between  the  fingers  and  toes,  about  the  wrists,  on  the  buttocks, 
abdomen,  and  the  upper  part  of  the  penis  (DaCosta). 

Symptoms. — The  disease  is  attended  with  excessive  itching, 
which  is  increased  at  night,  and  with  an  eruption  usually  due  to 
the  irritation  of  scratching.  At  the  close  of  our  civil  war  we  had 
a  form  of  itch  very  prevalent  in  this  country,  the  so-called  army 
itch,  which  was  a  very  chronic  affection  and  no  age  or  social 
state  was  exempt  from  it.     The  itching  was  intense  (DaCosta). 

Treatment. — Scabies  can  be  easily  cured.  The  treatment 
should  be  exclusively  local.  The  indications  are:  1.  To  destroy 
the  acari  and  their  eggs.  2.  To  do  so  without  irritating  the 
skin.  3.  To  remove  the  eruptions  called  forth  by  the  scratch- 
ing. At  the  Glasgow  Hospital  for  skin  diseases,  each  patient 
affected  with  scabies,  is  told  to  scrub  the  whole  of  his  body  (ex- 
cept the  head)  as  firmly  as  possible  with  black  soap  and  water, 
and  to  sit  in  a  hot  bath  for  twenty  minutes;  also  to  rub  some  of 
the  ointment  given  him  firmly  into  the  skin  of  the  whole  body 
(except  the  head)  for  twenty  minutes.  Let  the  ointment  remain 
on  the  body  all  night.  Repeat  these  processes  every  night  for 
three  nights,  hut  no  oftener.  Besides  the  above,  he  is  ordered  to 
put  all  his  washing  clothes  into  boiling  water,  and  to  iron  all 
others  with  a  hot  iron.  The  best  parasiticide  in  this  disease  is 
sulphur  '  but  it  is  apt  to  irritate  and  inflame  the  skin.  Anderson 
prefers  an  ointment  of  storax,  for  it  not  only  kills  the  acari,  but 
also  has  a  pleasant  aroma,  and  rather  soothes  than  irritates  the 
skin.  Burchard  strongly  recommends  the  use  of  balsam  of  Peru. 
One  thorough  application  to  the  dry  skin  is  sufficient,  or  the  bal- 
sam may  be  diluted  with  two  parts  of  lard  and  applied  oftener. 
Lard  may  alone  effect  a  cure  if  applied  for  two  weeks. 

SCARLET  FEVER. 

Called  also  scarlatina,  is  an  acute  infectious  and  contagious 
disease,  self-limited,  characterized  by  a  peculiar  exanthem,  an 
affection  of  the  throat  and  albuminuria,  and  terminating  in  des- 
quamation of  the  epidermis.  This  name  has  been  given  on 
account  of  the  bright  red  appearance  of  its  eruption.  It  is  a 
disease  of  childhood,  but  may  occur  at  any  age  (Bartholow  and 
Loomis). 


496  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Causes. — The  cause  of  scarlet  fever  is  a  contagion,  a  micro- 
organism, which  is  transferable  from  the  sick  to  the  healthy. 
No  specific  microbe  of  the  disease  has  as  yet  been  discovered.  It 
occurs  both  in  the  sporadic  and  epidemic  form,  but  never  arises 
spontaneously.  It  may  be  conveyed  by  contact,  through  the 
atmosphere,  by  animals,  and  by  clothing;  it  is  therefore  a  porta- 
ble disease.  An  epidemic  of  scarlet  fever  has  been  traced  to  the 
milk  supply.  Quain  says  :  "  Milk  is  a  great  medium  for  carry~- 
ing  scarlet  fever,  and  cream  even  more  than  milk  often  carries.it 
from  the  sick  to  the  well."  The  susceptibility  to  scarlatina  is 
not  universal.  Some  seem  to  have  a  certain  idiosyncrasy  which 
prevents  them  from  contracting  the  disease.  Scarlet  fever  can 
be  communicated  from  one  individual  to  another  by  inoculation 
with  the  serum  from  a  minute  vesicle  on  the  skin  of  a  scarlet 
fever  patient.  But  those  who  have  been  inoculated  for  scarlet 
fever  have  suffered  more  severely  than  those  who  con- 
tracted the  disease  in  the  ordinary  way.  The  scarlet  fever 
poison  can  be  conveyed  by  clothing,  but  when  a  physician 
makes  a  visit  of  ordinary  length,  he  is  not  likely  to  so 
convey  the  disease.  Nurses  who  have  been  with  a  scarlet  fever 
patient  for  a  number  of  days  and  whose  clothing  has  become 
filled  with  the  poison,  may  carry  the  disease.  The  poison  is 
probably  contained  in  the  skin  and  its  excretions  and  epithelium 
and  also  in  the  breath  and  exhalations  from  the  throat.  The 
period  at  which  the  disease  is  most  infectious  is  probably  the 
highest  point  of  the  disease;  but  it  is  present  at  any  period  from 
the  beginning  to  the  end.  The  disease  but  rarely  occurs  twice 
in  the  same  individual;  although  it  may  recur  from  one  to  three 
weeks  after  the  close  of  the  first  attack  and  is  then  de- 
scribed as  a  relapse.  The  period  of  incubation  varies  from  one  to 
fourteen  days,  the  average  duration  being  from  three  to  seven 
days.  The  shortest  period  is  that  of  a  patient  mentioned  by 
Trousseau,  in  whom  the  disease  appeared  in  a  day  after  expos- 
ure. Within  the  first  six  months  of  infant  life  there  is  little  lia- 
bility to  the  disease;  but  the  greatest  susceptibility  to  the  influ- 
ence of  the  poison  exists  between  the  second  and  seventh  years, 
and  declines  slowly  to  the  tenth,  and  after  this  more  rapidly; 
but  it  does  occur  in  old  age.     Those  who   have  .just    undergone 


SCAELET    FEVEE.  497 

surgical  operations  seem  to  be  especially  prone  to  contract  the 
disease.  Women  during  convalescence  after  child-birth  are  very 
liable  to  contract  scarlet  fever. 

Contagiousness. — The  area  of  the  contagiousness  of  scarlet 
fever  is  small;  it  apparently  embraces  only  a  few  feet.  It  is  not 
so  contagious  as  pertussis,  variola,  varicella,  or  measles. 

Variations  in  Type. — The  type  of  scarlet  fever  varies 
greatly  in  different  epidemics.  One  child  may  have  it  so  mildly 
that  little  treatment  is  required;  while  another  has  the  malignant 
form,  and  soon  succumbs  (Bartholow,  Flint,  Loomis  and  J.  L. 
Smith). 

Morbid  Anatomy. — It  has  no  characteristic  anatomical  lesions 
except  those  which  occur  in  the  skin  and  mucous  membranes. 
The  eruption  is  due  to  an  intense  hyperemia,  which  is  limited  to 
the  area  of  the  spots,  but  which  is  general  when  the  spots 
coalesce  (Bartholow  and  Loomis). 

Symptoms. — There  are  three  stages  of  scarlet  fever:  First, 
the  stage  of  invasion.  Second,  the  stage  of  eruption.  Third, 
the  stage  of  desquamation.  The  period  of  invasion  is  sudden 
and  violent.  A  strong  chill  is  the  initial  symptom  in  adults;  in 
children  there  is  a  violent  convulsion,  or  a  severe  attack  of  vom- 
iting, with  prostration.  Headache  of  a  very  intense  character, 
general  muscular  pains  and  high  fever  succeed  to  the  chill.  In 
a  short  time  the  temperature  rises  to  104°,  105°,  or  higher;  the 
skin  is  hot;  the  throat  burns  and  is  red  and  swollen;  the  tongue 
is  coated.  The  affection  of  the  throat  is  due  to  the  efflorescence 
which  appears  in  this  situation  before  its  appearance  on  the  skin. 
Epistaxis  is  common.  The  average  duration  of  this  stage  is 
about  twenty-four  hours,  and  the  eruption  usually  appears  on 
the  second  day.     It  may  appear  earlier  or  later. 

Stage  of  Eruption. — This  stage  in  children  is  sometimes 
ushered  in  by  a  transient  convulsion.  The  eruption  appears  on 
the  neck  and  upper  part  of  the  chest  first,  and  then  on  the  cheeks 
and  forehead.  The  first  appearance  is  in  the  form  of  minute  red 
<lots  or  specks,  and  these  may  coalesce  and  form  a  solid  redness. 
Exceptionally,  the  eruption  remains  punctiform,  that  is,  in  the 
form  of  distinct  maculae  or  spots.  The  redness  is  vermilion  or 
scarlet.     It  is  not  uniform  like  erysipelatous  redness,  but  on  close 


498  A   COMPEXDir^I   OF   peactical    medicine. 

inspection  the  patches  are  seen  to  be  studded  with  points.  The 
redness  momentarily  disappears  on  pressure,  and  white  lines  are 
produced  by  drawing  a  pointed  hard  substance  over  the  reddened 
surface.  In  some  cases  the  whole  cutaneous  surface  is  covered 
with  the  efflorescence  presenting  an  appearance  which  has  been 
compared  to  that  of  a  boiled  lobster.  The  integument  is  slightly 
swollen.  This  is  evident  of  the  face  and  is  apparent  to  the  pa- 
tient when  the  hands  are  closed.  The  feet  are  swollen.  The 
eruption  is  sometimes  accompanied  by  more  or  less  burning  and 
pruritus.  The  eruption  attains  its  maximum  of  intensity  and 
diffusion  on  the  third  day  after  its  Urst  appearance.  In  certain 
cases  the  erujDtion  may  be  slight  or  wanting. 

The  throat  is  more  or  less  affected  in  the  vast  majority  of 
cases.  The  tongue  is  coated  early,  and  while  the  coating  remains, 
frequently  the  papilla?  projecting  through  it  have  the  appearance 
of  a  number  of  red  points.  In  the  progress  of  the  disease,  the 
coatino-  exfoliates,  lea  vino;  the  surface  of  the  toncme  clean  and 
reddened;  and  the  papilla?  being  enlarged,  the  apjDearance  is 
strikingly  like  that  of  a  ripe  strawberry.  The  strawberry -like 
tongue  is  a  pathognomonic  symj)tom,  and  is  peculiar  to  this  dis- 
ease. The' pyrexia  is  not  diminished,  but,  as  a  rule,  is  increased 
after  the  appearance  of  the  eruption.  The  pulse  is  frequent, 
from  100  to  140  or  more,  is  quick  and  always  compressible,  and 
is  never  dicrotic.  The  skin  usually  is  dry  and  the  heat  as  felt  by 
the  hand  is  often  pungent.  The  thermometer  in  the  axilla  shows 
an  increase  of  temperature  to  105°  F.  and  in  severe  cases  it  may 
reach  112°  F.  The  duration  of  the  stage  of  eruption  in  the  ma- 
jority of  cases  is  between  four  and  six  davs. 

Stage  of  Desquamation. — With  the  disappearance  of  the  rash, 
desquamation  commences.  The  period  of  desquamation  lasts 
about  two  weeks,  during  which  time  there  is  the  greatest  danger 
of  communicating  the  disease.  At  the  end  of  this  period,  if  no 
complications  occur,  the  patient  is  well.  Where  the  skin  is  thick, 
as  on  the  palms  and  soles,  the  epidermis  peels  off  in  extensive 
patches.  The  entire  period  of  scarlet  fever  when  it  runs  its 
regular  course  is  from  two  to  three  weeks. 

Scarlet  fever  is  liable  to  irregularities.  In  a  certain  class 
of  cases,  complications  arise  from  the  overwhelming  of  the  cere- 


SC ABLET    FEVER.  409 

bro- spinal  system  with  the  scarlatina  poison.  In  these  cases 
there  are  delirium,  stupor,  restlessness,  wandering,  and  picking 
at  the  bed-clothes.  The  most  common  sequel  of  scarlet  fever  4s 
albwminwria  with  general  dropsy.  This  follows  the  disease  in  a 
considerable  proportion  of  cases.  The  time  of  its  occurrence  is 
between  ten  and  twenty  days  after  the  date  of  desquamation. 
The  symptoms  are  those  of  acute  diffuse  nephritis.  CEdema  of 
the  face  and  lower  extremities  is  first  observed,  aud  anasarca 
frequently  follows.  Effusion  sometimes  takes  place  into  the 
serous  cavities.  The  urine  is  scanty;  sometimes  it  has  a  smoky 
appearance,  and  it  may  be  distinctly  bloody.  It  is  usually  loaded 
with  albumin.  Ursemic  coma  and  convulsions,  pulmonary 
oedema,  and  oedema  of  the  glottis  are  grave  accidents  incident  to 
the  renal  affection.  Acute  nephritis  after  scarlet  fever  rarely 
ends  in  chronic  renal  disease.  Pleuritis,  pericarditis,  and  acute 
articular  rheumatism  are  occasional  sequels  as  well  as  concomi- 
tants of  scarlet  fever.  Chorea,  external  otitis  and  otitis  media 
are  sequels  in  some  cases.  A  purulent  discharge  takes  place 
from  the  ears,  and  sometimes  there  is  considerable  deafness.  A 
serious  complication  of  scarlet  fever  is  diphtheria  (Bartholow, 
Flint,  Loomis  and  J.  L.  Smith). 

Differential  Diagnosis. — Scarlet  fever  may  be  mistaken  for 
measles,  small-pox,  roseola  and  an  erythema  which  sometimes  ap- 
pears in  surgical  cases.  In  measles  the  appearance  of  the  erup- 
tion is  preceded  by  a  cough  and  coryza,  not  so  in  scarlatina.  Be- 
sides, the  eruption  of  measles  first  appears  on  the  face,  whereas 
the  eruption  of  scarlet  fever  first  appears  on  the  neck  and  chest. 
The  incubation  period  is  shorter  and  fever  higher  earlier  in  scarlet 
fever  than  in  measles.  In  small-p>ox,  the  eruption,  if  confluent, 
may  resemble  that  of  scarlet  fever  for  the  first  twenty-four  hours 
yet  the  development  of  the  first  vesicle  settles  the  question.  In 
erythema  the  redness  spreads  in  a  very  irregular  manner,  and  the 
throat  symptoms  and  strawberry-like  tongue  of  scarlet  fever  are 
absent.  In  roseola  the  throat  affection  is  much  milder  than  in 
scarlet  fever.  In  roseola  the  white  line  that  the  finger  leaves 
disappears  immediately,  while  in  scarlatina  it  remains  (Loomis 
and  Flint). 


500  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Prognosis. — Is  always  uncertain  in  scarlet  fever.  The  rate 
of  mortality  ranges  from  one  death  in  five  to  one  in  twenty.  The 
conditions  of  a  favorable  prognosis  are  early  eruption,  mild 
throat  symptoms,  a  temperature  not  higher  than  104°  F.,  pulse 
not  above  120  and  mild  cerebral  symptoms.  Autumn  is  the  most 
unfavorable  season.  Malignant;  cases  of  scarlet  fever  in  which 
no  eruption  appears,  prove  rapidly  fatal.  The  patient  is  over- 
whelmed by  the  scarlatina  or  active  blood  poison.  The  period 
of  greatest  mortality  is  from  infancy  to  five  years  of  age 
(Loomis). 

Treatment. — I.  Prophylaxis  or  Prevention. — The  jxrophy- 
laxis  of  scarlet  fever  is  a  system  of  the  strictest  quarantine.  The 
sick  must  be  removed  from  the  healthy.  Fresh  air  renders  the 
contagion  of  scarlet  fever  less  powerful;  therefore,  free  ventila- 
tion is  of  the  utmost  importance.  All  the  clothes  and  excretions 
of  the  patient,  the  nurse  and  everything  contaminated  by  the 
contagion  should  be  disinfected.  The  funeral  of  those  dying  of 
scarlet  fever  should  not  be  public.  The  sick  should  not  be 
allowed  to  leave  their  apartment  until  desquamation  is  com- 
pleted. Belladonna  has  no  power  to  prevent  this  disease,  as  was 
once  thought. 

II.  Medicinal  Treatment. — The  medicinal  treatment  of 
scarlet  fever  is  almost  entirely  expectant.  It  is  a  disease  which 
cannot  be  aborted,  but  tends  to  recovery.  The  bed  and  body 
linen  should  be  frequently  changed.  The  patient  should  be 
bathed  with  warm  water  once  or  twice  daily  during  the  period 
of  desquamation.  The  baths  will  relieve  the  kidneys  by  keeping 
the  skin  active.  If  the  temperature  of  the  patient  rises  above 
104°  F.,  it  should  be  reduced  by  some  means.  Loomis  says, 
"Unless  the  temperature  in  a  case  of  scarlet  fever  ranges  above 
105°  F.,  do  not  apply  cold  to  the  surface  or  give  antipyretics.'" 

In  all  cases  the  patient  is  tobe  sponged  frequently  with  tepid 
water,  and  if  there  is  intense  burning  of  the  surface,  a  saline  is 
to  be  added  to  the  water.  Sponging  in  this  manner  will  give  the 
patient  very  great  comfort.  Of  all  the  remedies  which  Loomis 
has  employed  for  the  throat  complications,  cold  carbonic  acid 
water  or  pieces  of  ice  afford  most  marked  relief.  In  the  ad- 
vanced stages  of  the  disease,  hot  applications  may  be  used  extern- 


SCLEROSIS    OF    THE    BKAIX.  501 

ally  to  the  neck  and  warm  water  gargles  and  steam  inhalations 
internally.  For  the  ulcers  sometimes  seen  in  the  throat  of  scarlet 
fever  patients,  a  spray  of  carbolic  acid,  tincture  of  iron,  chlorate 
of  potash,  or  tannic  acid  maybe  used.  Stimulants  may  be  given 
early  if  there  is  much  depression.  Whenever  kidney  symptoms 
are  developed,  dry  or  wet  cups  should  be  applied  over  the  region 
of  the  kidneys,  upon  either  side  of  the  spine.  At  the  same  time 
the  temperature  of  the  sick-room  is  to  be  raised  to  73°  or  74°  F., 
the  body  of  the  patient  covered  with  flannel,  hot-air  or  warm- 
baths  are  to  be  given  and  also  diuretics.  Of  the  diuretics,  digi- 
talis will  act  most  favorably.  Small  doses  of  calomel  may  be 
combined  with  the  digitalis  and  continued  for  two  or  three  days. 
The  patient  may  drink  water  freely.  If  convulsions  occur,  opium 
may  be  given  (Loomis). 

SCLEROSIS  OF  THE  BRAIN. 

By  the  term  sclerosis  is  meant  a  disease  characterized  by  the 
formation  of  isolated  patches  or  nodules  of  sclerotic  tissue  (har- 
dened tissue).  We  have  sclerosis  of  the  liver,  of  the  kidney,  of 
the  lung,  of  the  brain  and  spinal  cord,  etc. 

Independent  of  cerebro- spinal  sclerosis,  this  is  a  compara- 
tively rare  condition.  Cerebral  sclerosis  is  a  chronic  interstitial 
inflammation,  following  hyperemia  of  the  neuroglia.  It  may  be 
diffused  or  multiple  (Loomis). 

Morbid  Anatomy. — On  section,  masses  of  gray,  hard,  well- 
defined,  transparent  sclerotic  tissue  are  found,  varying  in  size 
from  one-fourth  to  one  inch  (Loomis). 

Causes. — Are  obscure.  It  is  intimately  connected  with 
changes  in  the  vascular  system.  Sclerosis  of  the  brain  is  often 
found  in  epileptics  and  in  the  insane  (Loomis  ). 

Symptoms. — Are  a  gradual  enfeeblement  of  the  mental 
powers,  especially  memory,  muscular  tremors,  headache,  dizzi- 
ness and  vertigo.  One  group  of  muscles  after  another  becomes 
paralyzed.  Melancholia,  pains  in  the  extremities,  and  a  sense  of 
formication  are  common.  Patients  may  gain  flesh  with  this 
disease.  Strabismus  may  be  present.  A  peculiar  symptom  is 
festination — the  patient  1  tends  forward  and  trots  along  like  one 


502  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

trying  to  run  after  he  is  tired  out.  In  rare  instances  the  first 
symptoms  are  convulsions  of  an  epileptiform  character,  followed 
by  hemiplegia  (Loomis). 

Differential  Diagnosis. — Sclerosis  of  the  brain  may  be  con- 
founded with  cerebral  softening,  paralysis  agitans  or  tumors. 
Softening  occurs  in  old  age  ;  sclerosis  occurs  from  youth  to 
middle  age.  The  paralysis  in  softening  is  in  one  set  or  group  of 
muscles,  and  if  it  extends,  does  so  in  an  orderly  manner.  There 
is  anwsthesia,  and  the  symptoms  develop  more  suddenly  than  in 
sclerosis.  Paralysis  agitans  is  marked  by  rhythmic  tremor 
passing  from  one  upper  to  the  corresponding  lower  limb;  there 
is  a  peculiar  deformity  of  the  fingers  and  toes;  the  facial  muscles 
are  not  affected,  and  the  patient  inclines  to  the  paralyzed  side  in 
walking.  Paralysis  agitans  occurs  only  after  the  fortieth  year, 
and  is  accompanied  by  no  cerebral  symptoms.  Cerebral  tumors 
are  attended  by  headache,  convulsions  and  signs  of  brain  irrita- 
tion without  loss  of  mental  power  (Loomis). 

Prognosis. — Sclerosis  of  the  brain  may  continue  from  five  to 
eight  years,  but  it  is  progressive  and  always  fatal  (Loomis). 

Treatment. — Little  can  be  done  for  this  disease  except  to  im- 
prove the  general  health.  Vulpian  recommends  chloride  of  iron, 
Mitchell  the  bi- chloride  of.  mercury,  Hammond  the  chloride  of 
barium  and  many  the  phosphate  of  zinc.  Nitrate  of  silver  and 
strychnia  are  said  to  relieve  tremor  (Loomis). 

CEREBROSPINAL  SCLEROSIS. 

Is  a  disease  characterized  by  the  formation  of  isolated 
patches  or  nodules  of  sclerotic  tissue  (hardened  tissue)  in  the 
brain,  pons,  medulla,  cerebellum  and  spinal    cord  (Bartholow). 

Morbid  Anatomy. — The  disease  in  the  brain  and  cord  to  the 
naked  eye,  appears  as  glistening  nodules  underneath  the  pia, 
varying  in  size  from  a  minute  object  to  that  of  a  walnut  (Bar- 
tholow). 

Causes. — The  exciting  causes  are  damp  and  cold,  sudden 
chilling  of  the  body,  traumatism,  severe,  long-continued  brain 
work  or  physical  exercise,  powerful  and  prolonged  moral  emo- 
tion,   chagrin   and    anxiety.      The   most   powerful   predisposing 


CEEEBRO    SPINAL    SCLEEOSIS.  503 

cause  is  heredity.  Continued  jarring  of  the  body  is  also  thought 
to  produce  the  disease.  It  occurs  in  nervous  people  with  hys- 
teria and  after  acute  febrile  diseases.  It  is  essentially  a  disease 
of  early  life,  few  cases  occurring  outside  the  limits  of  fifteen  and 
thirty -five  (Bartholow  and  Looniis). 

Symptoms. — It  may  be  insidious  or  sudden  in  its  develop- 
ment. If  it  come  on  insidiously,  the  patient  complains  vaguely 
of  headache,  vertigo,  muscular  weakness,  mental  disturbances, 
and  queer  feelings  as  formications,  itchings,  burnings,  etc.,  in  the 
limbs.  There  are  nausea,  vomiting,  cardialgia,  loss  of  co-ordin- 
ating power,  and  impairment  of  the  special  senses.  There  is 
more  or  less  paresis  in  the  extremities,  and  shaking  tremor  when 
an  attempt  is  made  at  voluntary  motions.  In  some  cases  the 
patient  becomes  childish  or  morose.  During  prolonged  fits  of 
yawning,  sobbing,  or  laughing,  the  respirations  become  stridulous. 
The  patient  talks  in  a  low  monotone  or  whisper,  dividing  his 
words  in  syllables,  and  empasizing  them  as  when  scanning  a  line 
of  poetry.  A  girdle  pain  is  felt  about  the  abdomen.  Amblyo- 
pia, nystagmus,  diplopia,  and  inequality  of  the  pupils  evidence 
invasion  of  the  base  of  the  brain  and  optic  tracts.  In  the  ad- 
vanced stage  acute  bed-sores,  loss  of  sexual  power  and  control  of 
the  sphincters  become  marked  symptoms  (Bartholow  and 
Loomis). 

Differential  Diagnosis. — Cerebro- spinal  sclerosis  may  be  mis- 
taken for  paralysis  agitans,  locomotor  ataxia,  and  cerebral  hem- 
orrhage. In  paralysis  agitans  the  fine  tremor  exists  when  the 
patient  is  at  rest,  and  is  not  accompanied  by  shaking  of  the 
head;  while  in  sclerosis  the  head  is  always  involved,  the  symp- 
tom ceasing  as  soon  as  the  patient  is  at  rest.  Paralysis  agitans 
is  rare  before  forty;  and  multiple  sclerosis  is  rare  after  thirty - 
five.  Changes  in  the  voice  and  speech  and  ocular  symptoms  are 
present  in  disseminated  sclerosis  and  absent  in  paralysis. 

In  locomotor  ataxia,  the  peculiar  tremor,  impairment  of  voice 
and  speech,  and  nystagmus  that  belong  to  disseminated  sclerosis 
are  absent.  In  the  former  disease  we  notice  the  peculiar  iron- 
band  sensation,  vesical  symptoms,  the  Meniere's  vertigo,  the  very 
slow  and  late  appearance  of  paretic  symptoms,  the  lightning-like 
and  agonizing  neuralgic  pains,  and  the  peculiar  double  beat  in 


504  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

walking,  the  heel  being  put  down  first,  all  of  which  are  in  marked 
contrast  to  the  symptoms  of  multiple  cerebro- spinal  sclerosis. 
When  sclerosis  is  ushered  in  by  loss  of  consciousness  which 
rapidly  deepens  into  coma,  with  marked  hemir)legic  symptoms,  it 
may  be  mistaken  for  cerebral  hemorrhage /  but  in  sclerosis  the 
temperature  is  very  high  during  these  peculiar  attacks — 104°  or 
105°  F., — the  hemiplegia  passes  off  soon  (Loomis). 

Prognosis. — The  average  duration  of  this  disease  is  five  to 
ten  years.  The  termination  by  death  is  the  only  one  known. 
After  six  or  seven  years  emaciation  sets  in,  a  marasmus  is  devel- 
oped, and  the  patient  is  apt  to  die  from  intercurrent  disease 
(Bartholow  and  Loomis). 

Treatment. — Improve  the  nutrition.  Chloride  of  gold,  phos- 
phate of  zinc,  nitrate  of  silver,  chloride  of  barium,  potassium, 
iodide  and  bromide,  arsenic,  belladonna,  calabar  bean,  and  ergot 
have  all  been  used  with  some  success.  The  galvanic  current 
benefits  in  some  cases.  For  the  pain  morphine  should  be  given 
(Bartholow  and  Loomis). 

SCROFULA. 

Is  a  constitutional  dyscrasia,  hereditary  or  acquired,  charac- 
terized by  changes  inflammatory  and  hyperplastic,  occurring  for 
the  most  part  in  the  lymphatic  system,  the  skin,  mucous  mem- 
branes, connective  tissue,  osseous  structures  and  viscera. 
Scrofula  is  also  known  as  struma,  the  strumous  diathesis,  tuber- 
culosis, the  tuberculous  diathesis.  Scrofula  is  a  disease  chiefly  of 
infancy  and  childhood,  but  early  adult  life  is  not  entirely  exeunt. 
Scrofulous  persons  are  liable  to  chronic  inflammations  of  the 
lymphatic  glands,  especially  those  of  the  neck,  which  enlarge, 
often  coalesce  with  each  other,  and  undergo  cheesy  metamorpho- 
sis (Bartholow,  Loomis  and  Smith). 

Morbid  Anatomy. — The  characteristic  lesions  of  scrofula  are 
to  be  found  in  the  lymphatic  glands,  although  the  skin,  mucous 
membranes,  bones,  joints,  and  organs  of  special  sense  may  be  in- 
volved. Anaemia  necrosis  or  suppuration  sometimes  occurs  in 
the  glands.  On  the  skin  the  lesions  appear  as  eruptions.  Im- 
petigo of  the  eyelashes  and  external  otitis  are  common  strumous 


SCROFULA.  505 

diseases.  Scrofulous  inflammation  of  mucous  membranes  is 
marked  by  a  thick,  sticky  exudation  with  a  tendency  to  form 
scabs.  The  bones  most  frequently  involved  are  those  of  the 
ankle,  lower  part  of  the  femur,  and  the  vertebrae.  The  scrofulous 
development  may  assume  the  form  of  synovitis,  osteitis,  perios- 
teitis,  or  general  arthritis.  A  pharyngitis  often  gives  rise  to 
hyperplasia  of  the  tonsils  (which  are  lymphatic  glands)  in  scrof- 
ulous individuals  (Loomis). 

Causes. — Scrofula  is  congenital  or  acquired.  The  children 
of  intenrperate,  phthisical,  syphilitic,  cancerous  and  very  old  or 
very  young  parents,  develop  early  all  the  characteristic  features 
of  the  scrofulous  diathesis.  Children  of  consanguineous  mar- 
riages are  especially  liable  to  scrofula,  and  to  this  has  been  attri- 
buted the  scrofula  of  royal  families.  Healthy  children  may  ac- 
qire  scrofula  through  antihygienic  surroundings,  from  improper 
food,  overcrowding,  lack  of  fresh  air,  exercise  and  sunlight.  In 
the  infant  scrofula  is  sometimes  produced  by  insufficiency  or 
poor  quality  of  the  breast-milk,  or  too  protracted  nursing  at  the 
breast.  Some  think  that  scrofula  is  a  local  tuberculosis  from 
the  fact  that  scrofulous  glands  sometimes  contain  the  tubercle 
bacillus.  Birch -Hirchf eld  found  tubercles  in  nine  out  of  ten 
lymphatic  glands  removed  from  the  necks  of  scrofulous  patients. 
Others  think  that  the  tubercle  bacillus  found  in  scrofulous 
glands  is  accidental.  Rabl  tabulates  1,000  cases  of  scrofula  as 
regards  the  causation,  as  follows:  79  had  scrofulous  parents,  446 
had  tuberculous  parents,  356  lived  in  damp  dwellings,  25  were 
subjected  to  other  bad  hygienic  surroundings,  69  could  be  as- 
cribed to  acute  infectious  diseases,  such  as  small-pox,  measles, 
scarlet  fever,  etc.,  14  to  vaccination,  7  to  decrepitude  and  4  to 
consanguinity  of  parents.  Rabl  also  expresses  the  opinion  that 
in  certain  cases  scrofula  results  from  syphilis  in  the  parent  or 
grand-parent.  He  believes  that  syphilis  in  the  parent  causes 
scrofula  in  the  child  by  diminishing  the  power  of  resistance  to 
the  causes  which  produce  the  latter  affection.  He  thinks  that  in 
this  matter  parental  syphilis  gives  rise  in  some  children  to  symp- 
toms identical  with  those  of  scrofula,  while  in  other  children  it 
gives  rise  to  syphilitic  symptoms.  Dr.  J.  L.  Smith  is  of  the  same 
opinion  (Bartholovv,  Loomis  and  J.  L.  Smith). 


506  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms, — Some  children  with  a  scrofulous  habit  have  a 
transparent,  white  skin,  with  delicate  blue  veins;  large,  lustrous 
eyes;  bright  red  lips,  etc.  Others  may  have  large  heads  with 
coarse  features,  a  thick  skin,  which  has  a  flabby,  spongy  feel,  an 
enlarged  abdomen,  and  cervical  glands.  Chronic  inflammations 
of  the  skin  about  the  face  and  scalp  are  frequent.  Coryza,  con- 
junctivitis, otorrhcea,  laryngitis  and  bronchitis  are  persistent. 
Synovitis  may  appear.  A  slight  injury  may  be  the  starting 
point  of  caries  and  necrosis.  Glandular  enlargements  are  the 
most  common  symptoms.  This  enlargement,  which  is  non-inflam- 
matory and  due  to  cellular  hyperplasia,  is  very  gradual,  and 
forms  a  smooth,  Arm  tumor.  These  glands  may  inflame  and  sup- 
purate. The  disease  progresses  slowly,  but  toward  puberty  pul- 
monary disease  is  apt  to  be  established  (Loomis  and  Smith). 

Prognosis. — Is  good  when  the  patient  is  seen  early.  Scro- 
fulous children  may  die  from  tuberculous  intestinal  disease, 
acute  hydrocephalus  or  croup. 

Treatment. — The  diet  should  be  nutritious  and  easily  di- 
gested. Cod-liver  oil  should  be  given  daily  during  the  greater 
part  of  infantile  and  adult  life.  The  syrnp  of  the  iodide  of  iron 
should  be  given  in  one  to  two -drop  doses  three  times  daily  to  a 
child  of  six  months,  and  five  drops  to  a  child  of  four  years.  The 
following  is  a  good  formula: 

Jfc     Olei  morrhuse §iv. 

Syrupi  calcis  lactophosphatis 

Aqua3  calcis — aa §ij . — M. 

Sig. :     One  teaspoonful  to  a  dessertspoonful  four  times  daily. 

—Smith. 

Fresh  air,  outdoor  exercise  and  daily  bathing  are  necessary. 
Farm-life,  sea-air  and  sea-bathing  have  been  found  efiicacious. 
The  following  is  a  useful  iodine  mixture  for  external  application: 

Tfr    Liquor  iodini  composita 

Gly  cerina? — aa. 5j  • — M. 

Sig. :     To  be  applied  over  the  gland  as  an  inunction. 

The  synovitis  or  strumous  arthritis  must  be  treated  appropri- 
ately when  it  occurs.  When  it  occurs  in  two  or  more  joints,  it 
may  be  mistaken  for  rheumatism  (Loomis  aud  Smith). 


SCURVY.  507 

SCURVY. 

Called  also  scorbutus,  is  a  chronic  blood  disease,  which  may 
be  regarded  as  a  peculiar  form  of  anseinia  arising  from  deficiency 
of  vegetable  diet.  This  disease  appears  to  have  been  known  to 
the  ancients.  During  the  last  five  or  six  centuries  it  prevailed 
very  entensively  in  armies  and  among  crews  of  sailing  vessels, 
and  hence  it  was  called  sea-scurvy.  It  prevailed  enormously  in 
the  English  and  French  armies  in  the  Crimean  War,  and  also  in 
the  late  Civil  War  in  our  own  country  (Flint  and  Loomis). 

Causes. — Deprivation  of  fresh  vegetable  food  for  along  time 
will  very  surely  induce  scurvy.  It  is  rarely  met  with  from  any 
other  cause,  although  an  unvaried  diet  of  poor  quality  may  in- 
duce it  (Loomis). 

Symptoms. — The  skin  of  the  face  and  eyelids  changes  color 
and  appears  bruised  and  swollen.  The  pulse  is  soft  and  the 
temperature  lower  than  normal.  There  is  great  despondency 
and  a  sense  of  weight  in  the  lower  limbs.  The  skin  is  dry,  rough 
and  of  a  muddy  pallor.  The  conjunctivae  are  pearly  white,  the 
tongue  is  clean  and  pale,  the  teeth  loosen  and  are  surrounded  by 
bright  red  ulcerated  and  spongy  gums  which  bleed  upon  the 
slightest  provocation.  The  breath  is  exceedingly  offensive,  fre- 
quently from  necrosis  of  the  jaws.  Ecchymoses  and  -petechial 
spots  cover  the  body.  Severe  darting  pains  are  felt  in  the  limbs. 
about  the  calf  of  the  leg  and  the  popliteal  space.  Node-like 
swellings  occur  over  the  tibia.  Slight  exertion  may  occasion 
palpitation,  dyspnoea,  and  even  syncope  (Flint  and  Loomis). 

Differential  Diagnosis. — Scurvy  may  be  mistaken  for  mercu/r- 
ial poisoning  and purpwa.  The  history  of  the  case  and  a  close 
inspection  of  the  gums  will  enable  one  to  distinguish  scurvy 
from  mercurial  poisoning.  Scurvy  is  distinguished  from  pur- 
pura by  the  spongy  gums,  painful  swellings,  and  more  profuse 
though  less  numerous  hemorrhages.  Purpura  is  not  affected  by 
lime  juice,  or  change  in  diet,  while  scurvy  is  (Loomis). 

Prognosis. — Scurvy  is  not  a  fatal  disease,  if  uncomplicated, 
and  appropriate  treatment  applied.  It  Aras  the  cause  of  death 
in  a  large  proportion  of  those  who  died  during  the  potato 
famine  in  Ireland  (Loomis). 


508  A    COMPENDIUM    OF    PE ACTIO AL     MEDICINE. 

Treatment. — Iu  long  sea- voyages  or  campaigns  lemon  or 
lime  juice  or  citric  acid  should  be  taken  daily  when  fresh  or  pre- 
served vegetables  cannot  be  obtained.  By  their  use  in  the 
English  navy,  scurvy  has  been  diminished  nearly  ninety  per 
cent.  Orange-juice  is  also  an  effectual  antiscorbutic.  One  of 
the  most  efficient  of  antiscorbutic  vegetables  is  the  potato.  It  is 
most  efficient  when  eaten  raw.  Pickles,  onions,  raw  cabbage  or 
sauerkraut,  the  water- cress,  green  corn  and  green  apples  are 
valuable  antiscorbutics.  One  who  is  seriously  ill  of  scurvy 
should  be  kept  in  bed,  and  his  diet  should  be  fresh  vegetables 
and  acid  fruits  with  fresh  meats.  Three  or  four  ounces  of  lime 
or  lemon  juice  largely  diluted  with  cold  water  should  be  taken 
daily.  Tincture  of  the  chloride  of  iron  and  ergot  are  given  to 
arrest  hemorrhage.  Whiskey  may  be  given  when  indicated.  To 
arrest  local  hemorrhage,  alum,  tannin,  subsulphate  of  iron  and 
the  chloride  of  iron  are  most  useful.  A  wash  of  chlorate  of 
potash  will  afford  relief  to  the  mouth  symptoms.  Quinine,  iron 
and  strychnine  act  both  as  tonics  and  appetizers  (Flint  and 
Loomis). 

SEA=SICKNESS. 

Is  a  peculiar  form  of  functional  disturbance  of  the  nervous 
system  characterized  by  severe  depression  and  persistent  nausea 
and  vomiting  (Loomis). 

Causes. — Sea -sickness  is  most  commonly  the  result  of  the 
motion  of  a  ship,  but  it  may  be  the  result  of  any  unusual 
motions  to  which  the  person  is  unaccustomed,  as  the  motion  of  a 
swing  or  an  elevator.  Waltzing,  riding  backwards,  turning  a 
somersault,  or  the  sudden  jerk  of  a  railroad  train  as  it  starts  or 
stops  may  each  produce  a  similar  condition.  In  some  persons,  a 
mild  form  of  sickness  may  be  produced  by  simply  watching 
oscillating  objects.  Some  persons  never  suffer,  while  others  are 
unable  to  endure  the  slightest  motion  on  the  water  or  elsewhere. 
The  nerve  centres  are  embarrassed,  and  the  resulting  nervous 
irritation  manifests  itself  through  vaso-motor  disturbances  in 
precisely  the  same  manner  as  is  seen  when  persons  blush  under 
embarrassing  circumstances,  or  pale  when  startled  (Loomis). 


SEA-SICKXESS.  509 

Symptoms. — Seasickness  usually  presents  the  two  stages  of 
first,  depression  and  exhaustion,  and  second,  reaction.  It  begins 
with  a  sense  of  weight  and  epigastric  oppression,  occuriug  only 
during  the  rapid  rise  and  fall  of  the  vessel.  It  speedily  becomes 
continuous  and  is  accompanied  by  vertigo  and  headache.  Xausea 
is  always  most  intense  and  at  the  same  time  the  vomiting  is  often 
sudden  and  projectile,  as  in  cerebral  vomiting.  The  appetite  is 
entirely  lost.  The  mental  depression  is  great.  In  the  majority 
of  cases  this  condition  continues  from  three  to  five  days,  provided 
the  voyage  is  of  that  length  during  which  time  the  nausea,  vomit- 
ing and  mental  depression  continue  and  is  then  followed  by  reac- 
tion. There  is  now  a  ravenous  appetite  and  a  feeling  of  well  being. 
In  some  cases  the  stage  of  depression  lasts  for  weeks,  and  the  pa- 
tient may  pass  into  a  stage  of  partial  collapse  and  coma 
(Loomis). 

Prognosis. — It  is  very  rarely  fatal,  but  occasionally  a  condi- 
tion of  collapse  develops  which,  if  not  assiduously  treated,  may 
pass  into  coma  and  death  (Loomis). 

Treatment. — For  the  vaso-motor  disturbance  and  spinal  con- 
gestion, counter -irritation  to  the  spine,  or  ice-bags  and  the  bro- 
mides and  nitrite  of  amyl  have  proved  the  most  useful.  The  ice- 
bag  controls  the  spinal  congestion.  The  bromides  must  be  be- 
gun some  time  before  the  voyage  and  continued  in  large  doses 
until  the  patient  is  accustomed  to  the  motion.  Amyl  nitrite 
seems  to  be  the  most  efficacious  remedy  yet  proposed.  It  should 
be  given  in  full  doses  upon  the  first  appearance  of  epigastric  dis- 
tress and  repeated  as  necessary.  Dr.  Clapham  reports  121  suc- 
cessful cases  out  of  a  total  of  124  in  which  amyl  nitrite  was  used. 
Sometimes  stimulants  are  effective  but  often  fail  (Loomis).  Ac- 
cording to  Bartholow  sea-sickness  is  relieved  sometimes  by  the 
subcutaneous  injection  of  atropine  in  small  quantity.  A  little 
chloroform  (ZHii-ZHv.)  dropped  on  sugar  and  swallowed  is  some- 
times effective  in  sea-sickness.  Chloral  in  fifteen  to  thirty  grain 
doses  every  four  hours,  is  probably  the  most  effective  remedy, 
but  it  must  be  given  before  decided  nausea  sets  in.  The  bromide 
of  sodium  in  half  to  one  drachm  doses  before  embarking  is  one 
of  the  first  remedies  in  sea-sickness.  Nitro-glycerine  by  the 
stomach  may  afford  relief  (Bartholow  ). 


510  A    COMPENDIUM    OF    PRACTICAL     MEDICIJSTE. 

SEPTICEMIA. 

Is  a  constitutional  disease  due  to  the  absorption  into  the 
blood  of  a  septic  material  which  is  developed  in  decomposing 
animal  matter  by  the  action  of  putrefactive  bacteria.  The  dis- 
ease is  closely  allied  to  surgical  or  traumatic  fever  (Loomis). 

Causes, — The  nature  of  the  septic  poison  is  still  a  matter  of 
dispute.  Some  claim  that  it  is  a  chemical  substance  formed  in  a 
wounded  part,  while  others  regard  the  bacteria  the  sole  cause  of 
the  septic  infection.  Decomposing  tissues  which  cause  septi- 
caemia may  be  in  the  body,  on  the  surface  of  the  body,  or  outside 
of  the  body. 

I.  Thus,  a  decomposing  placenta  in  utero,  sloughing  ulcers 
in  typhoid,  necrotic  processes  in  chronic  phthisis,  diphtheritic 
sloughs,  ulcerative  endocarditis,  abscess  and  gangrene  of  the 
lung — these  are  some  of  the  internal  conditions  which  may  induce 
septicaemia. 

II.  Wounds,  gangrene,  decomposing  membranes,  or  sup- 
puration and  necrosis  in  small-pox,  any  ill-conditioned  wound, 
especially  if  lacerated  and  contused,  may  cause  septicaemia. 

III.  Dissecting  wounds  and  ^os^-mortem  manipulation  of 
those  who  have  died  of  infection,  even  without  a  surface  abra- 
sion, may  induce  septicaemia.  The  respiratory  and  the  gastro- 
intestinal tracts  are  sometimes  the  mode  of  entrance  of  the  infec- 
tion (Loomis). 

Symptoms. — The  symptoms  of  septicaemia  or  blood-poison- 
ing will  vary  with  the  amount  of  the  septic  material  introduced 
into  the  system  and  the  length  of  the  infection.  In  a  well- 
marked  case,  after  a  rigor,  or  feeling  of  chilliness,  but  rarely  a 
distinct  chill,  there  is  a  rapid  rise  in  temperature;  105°  or  107° 
F.  may  be  reached  within  the  first  twenty-four  hours.  The  pulse 
is  rapid,  120  to  140,  feeble  and  thread-like.  The  mouth,  tongue, 
and  surface  of  the  body  become  hot  and  dry.  If  sweats  occur 
they  are  very  slight.  Vomiting  is  frequent.  The  countenance 
is  dull,  and  the  patient  generally  free  from  pain.  There  is  rest- 
lessness and  low  muttering  delirium.  The  respirations  are  feeble, 
labored,  and  hurried.  The  skin  may  be  slightly  jaundiced. 
Diarrhoea  is  present  in  nearly  all  severe  cases.     In  severe  cases 


SEPTICEMIA SPERMATORRHOEA  511 

death  may  occur  within  twenty -four  to  seventy- two  hours,  the 
patient  dying  in  complete  collapse.  Typhoid  symptoms,  a  dry 
tongue,  rise  in  temperature,  diarrhoea  and  muttering  delirium, 
following  an  abortion  or  child-birth,  should  always  excite  sus- 
picion (Loomis). 

Differential  Diagnosis. — Septicaemia  may  be  mistaken  for 
py'cemia.  Pycemia  is  ushered  in  by  a  distinct  chill;  septicaemia 
by  a  slight  chill.  In  pyaemia  the  chills  recur;  in  septicaemia 
there  is  but  one  chill.  In  pyaemia  there  are  profuse  sweats, 
which  recur;  in  septicaemia  there  are  slight,  if  any,  sweatings, 
and  they  are  never  recurrent.  In  pyaemia  the  temperature  grad- 
ually rises  to  102°  to  104°  F.;  in  septicaemia  it  is  high  at  the 
onset,  105°  to  107°  F.  There  is  a  sweet  "sickisk"  odor  to  the 
breath  in  pyaemia,  absent  in  septicaemia.  Pyaemia  develops 
slowly,  sejrticaemia  rapidly  (Loomis). 

Prognosis, — When  the  symptoms  of  the  disease  are  well 
marked  the  ju'ognosis  is  bad.  Its  duration  is  from  two  days  to 
two  months. 

Treatment. — Discover  and  when  possible  remove  the  cause. 
Antiseptics  should  always  be  used  at  the  seat  of  the  infection. 
The  bowels  must  be  freely  acted  upon  by  salines  throughout  the 
whole  course  of  the  disease.  Quinine,  salicylic  acid  and  brandy 
are  the  three  drugs  on  which  we  place  our  reliance.  Tanner 
recommends  quinine  and  nitric  acid.  The  diet  must  be  as  nour- 
ishing as  possible.  Billroth's  treatment  is  cooling  drinks,  a  fever 
diet,  morphine  at  night  to  secure  sleep,  from  six  to  ten  grains  of 
quinine  during  the  afternoon  and  warm  baths  (Loomis). 

SPERMATORRHEA. 

Is  an  escape  of  seminal  fluid  containing  spermatozoa,  without 
ejaculation  and  without  pleasurable  orgasm,  usually  at  stool, 
with  the  urine,  or  to  a  slight  extent  at  all  times.  During  pro- 
longed erection  under  intense  sexual  excitement,  a  small  amount 
of  true  seminal  fluid  is  apt  to  escape  into  the  prostatic  sinus,  and 
to  be  passed  at  the  next  urination.  This  may  happen  to  any  one 
occasionally,  and  does  not  amount  to  disease  (Keyes). 


512  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Varieties. — I.  True.  Spermatorrhoea.  II.  False  Sper- 
matorrhoea. 

True  spermatorrhoea  may  exist,  but  it  is  a  very  rare  disease. 
It  falls  to  the  lot  eveu  of  the  specialist  to  see  but  very  few  cases 
of  true  spermatorrhoea. 

False  spermatorrhoea,  is,  however,  a  more  common  com- 
plaint. It  is  supposed  to  be  present  when  nocturnal  emissions 
are  frequent,  when  diurnal  emissions  take  place  on  any  sexual 
thought,  and  urethral  discharge  of  a  glairy  fluid  attends  defeca- 
tion, when  erections  with  discharge  follow  the  slightest  irritation, 
such  as  that  produced  by  riding  or  walking,  from  the  friction  of 
trousers,  etc.  Such  cases  are  common  and  are  usually  clue  to 
masturbation,  but  are  not  cases  of  true  spermatorrhoea,  although 
they  often  preceed  it.  Nocturnal  emissions  may  be  too  frequent; 
but  if  associated  with  sexual  feeling,  they  are  natural.  If 
too  frequent,  they  should  be  checked  as  they  may  lead  on  to  the 
true  disease.  The  glairy  fluid  pressed  out  in  defecation  is  rarely 
seminal,  but  is  prostatic,  of  a  transparent,  tenacious  character, 
and  not  milky.  Most  of  the  symptoms  Avhich  a  patient  usually 
mistakes  for  spermatorrhoea  are  a  gleety  discharge,  phosphatic 
urine,  vesical  mucus,  decomposing  urine,  etc.  The  young  man 
into  whose  hands  some  pamphlet  on  "  Manhood  Restored  "  has 
fallen,  imagines  himself  hopelessly  doomed  to  impotence,  paraly- 
sis, and  idiocy,  because  the  rjamphlet  tells  him  that  he  has  sper- 
matorrhoea, which  spermatorrhoea  consists  in  nocturnal  pollution, 
escape  of  mucus  during  prolonged  erection,  of  phosphates  in  the 
urine,  etc.  Sometimes,  where  the  diseased  mind  of  a  youth  suf- 
fering from  ungratified  sexual  desire  can  find  nothing  else  to  con- 
firm its  suspicions,  the  natural  healthy  flocculent  cloud  of  mucus 
collecting  normally  in  all  urine,  after  it  has  stood  awhile,  is 
pointed  to,  in  dejected  triumph,  as  a  demonstration  of  the  never- 
ending  loss  of  seminal  fluid  (Bryant  and  Keyes). 

Causes. — Spermatorrhoea  sometimes  follows  excessive  mas- 
turbation, general  prostration,  as  after  typhoid  fever,  imperfect 
digestion  and  general  nervous  distress  from  overwork,  or  other 
cause,  or  follow  chronic  disease  of  the  prostatic  sinus  and  semiual 
vesicles.  It  is  sometimes  associated  with  constipation  and  rectal 
irritation,  spasmodic   action  of   the  levator    ani    acting    on  the 


SPEEMATOEEHCEA.  513 

vesicular  seminales  and  prostate  gland.  The  worst  cases  are  asso- 
ciated with  wasting  of  the  testicles  and  varicocele.  It  is  some- 
times due  to  excess  of  venery.  Lallemand  holds  that  sperma- 
torrhoea is  nearly  always  dependent  upon  irritation  of  the  pros- 
tate gland  and  its  ejaculatory  ducts.  Trousseau  believes  that 
spermatorrhoea  or  incontinence  of  semen  is  due  to  some  imper- 
fection in  the  nervous  system  of  organic  life,  since  it  is  so 
commonly  found  in  men  who  have  had  incontinence  of  urine  in 
childhood  (Bryant  and  Keyes). 

Symptoms. — In  true  spermatorrhoea  it  is  usual  for  spermatic 
fluid  in  small  quantity  to  pass  from  the  meatus  during  defecation 
and  urination;  while  jolting  or  riding,  etc.,  cause  oozing  of  a 
bluish  fluid  from  the  meatus,  which  contain  spermatozoa.  Pa- 
tients with  true  spermatorrhoea  have  little  care  for  their  sexual 
functions  and  are  not  disturbed  on  the  subject  of  impotence  and 
present  in  this  respect,  a  most  strongly  marked  contrast  with  the 
hypochondriacal  patients  imagining  themselves  impotent  from 
false  spermatorrhoea.  Patients  with,  true  spermatorrhoea  are  not 
by  any  means  necessarily  impotent,  but  their  sexual  appetite  is 
usually  morbid,  excessive  or  feeble  perhaps  unnatural  and  per- 
verted, while  sexual  power  is  generally  diminished.  According  to 
Bryant,  spermatorrhoea  commences  almost  always  with  nocturnal 
emissions  which  gradually  become  more  frequent.  These  are  at 
first  attended  with  erotic  sensation,  but  finally  occur  without 
erection.  If  copulation  be  attempted  the  ejaculation  takes  place 
at  once,  often  before  the  introduction  of  the  organ.  In  many 
cases  the  general  symptoms  are  those  of  great  lack  of  nervous 
tone,  dyspepsia,  headache,  melancholy,  neuralgia,  loss  of  spirits, 
23ains  in  the  back,  groins,  testicles  and  vesical  irritability.  Such 
patients  tend  to  grow  thin,  to  lose  their  ambition  and  to  fret.  At 
last  the  penis  shrivels,  the  testicles  become  small,  flabby  and  very 
sensitive  and  the  patient  becomes  truly  impotent,  incapable  of 
erection.  This  malady  does  not  kill.  Dr.  Keyes  knows  an  old 
gentleman  who  enjoys  excellent  health  and  who  has  had  true 
spermatorrhoea  more  than  fifty  years  (Bryant  and  Keyes). 

Treatment. — Many  cases  are  positively  incurable,  some  get 
well — medicine  is  of  little  or  no  value.  It  is  unfortuate  that  so 
many  text-books  ascribe  value  to  the  use  of  drugs  in  this  malady. 


514  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

All  the  hygienic,  general  and  local  measures  advised  for  cases  of 
pollution  may  be  tried.  The  use  of  the  steel  sound  helps  to  give 
tone  to  the  parts.  Rouband  thinks  well  of  ergot — two  to  eight 
grains  daily — in  atonic  cases.  The  use  of  a  local  astringent  to 
the  prostatic  sinus  is  often  of  marked  advantage.  The  best  agent 
for  effecting  this  is  nitrate  of  silver  in  solution  (gr.  x.  to  5j  to 
the  ounce),  three  to  five  drops  of  this  thrown  into  the  deep 
urethra.  Bryant  thinks  half- grain  doses  of  the  extract  of  bella- 
donna twice  a  day,  with  some  tonic  such  as  iron,  zinc,  strych- 
nine, or  quinine,  are  valuable.  The  rectum  should  be  kept 
empty  by  a  nightly  injection  of  cold  water.  If  a  positive  local 
treatment,  with  perhaps  some  tonics  when  required,  fails  to  cure, 
the  patient  will  be  wise  to  accept  his  malady  as  he  would  some 
deformity  which  others  cannot  see,  and  think  as  little  of  it  as 
possible,  keeping  his  mind  pure  and  his  thoughts  away  from  the 
subject  (Bryant  and  Keyes). 

STRANGURY. 

Is  the  painful  passing  of  urine  in  drops.  It  is  not  a  disease 
but  a  symptom.  The  following  prescriptions  have  been  tried 
and  recommended : 

Jfc     Tincturse  cannabis  indicse §ij. 

Sig. :     A  half-teaspoon ful  every  few  hours.     (When  strangury  is 
due  to  spinal  disease  with  bloody  urine.)  — Ringer. 

Jfc     Pulv.  opii gr.  ii.-iv. 

Olei  theobromse. . , 3J. — M. 

Ft.  suppositoria  no.  ii. 
Sig.:     Introduce  one  into  the  bowel,  and  repeat  if  necessary  in 
four  hours.  — Hartshorne. 

STYE. 

Called  also  hordeolum,  is  a  small  red  and  painful  swelling 
situated  on  the  outer  surface  of  the  lid  or  near  its  margin,  and 
consists  in  a  circumscribed  phlegmonous  inflammation  of  the  lid 
dependent  on  morbid  change  in  the  Meibonian  glands.  (Bryant 
and  Xoyes). 

Causes. — Styes  generally  occur  in  weakly,  delicate  persons, 
and  are  apt  to  be  associated  with  chronic  blepharitis  or  conjunc- 


STYE SPINA    BIFIDA.  515 

tivitis,  and  often  depend  on  general  debility.  Another  frequent 
concomitant  and  favoring  condition  is  nasal  catarrh,  which  will 
also  need  attention.  Several  styes  may  appear  simultaneously, 
or  there  may  be  a  succession  of  them.  They  give  rise  to  con- 
siderable irritation  and  are  often  extremely  painful.  The 
inflammation  usually  goes  on  to  suppuration  (Bryant  and  Noyes). 
Treatment. — In  its  inception  it  may  sometimes  be  checked 
by  applying  a  bit  of  ice  wrapped  in  muslin  for  a  few  minutes 
repeatedly,  or  by  pulling  the  cilium  which  passes  through  it. 
When  suppuration  is  unavoidable,  a  poultice  of  ground  slippery 
elm  bark  is  most  comforting,  and  a  puncture  should  be  made  at 
an  early  period.  Good  living,  general  tonics,  and  mild  astrin- 
gents are  the  proper  remedies  to  prevent  their  recurrence;  but  it 
is  important  also  to  investigate  the  state  of  refraction,  because 
what  causes  eye  strain  will  provoke  styes  (Noyes).  The  follow 
ing  lotion  may  be  of  service: 

JJr     Acidi  boracici 3iss. 

A  quae  destillatse , §v. — M. 

Sig. :     Apply  to  the  eyelids  several  times  daily.  — Abadie. 

SPINA  BIFIDA. 

Called  also  hydrorachitis,  is  a  congenital  defect  of  the  ver- 
tebral column,  accompanied  by  a  protrusion  of  the  surrounding 
membranes  of  the  cord,  due  to  an  arrest  of  ossification  of  the 
vertebras  of  the  foetus  at  this  point.  It  is  essentially  a  congenital 
hernia  of  the  membranes  of  the  cord  through  an  opening  in  the 
spine.  It  is  analogous  to  the  meningoceles  of  the  cranium,  and 
is  similar  in  nature  to  hare-lip  and  cleft  palate.  The  liquid  in 
hydrorachitis  is  simply  a  portion  of  the  cerebro-sjDinal  fluid 
which  normally  exists  in  the  subarachnoid  space  in  the  brain  and 
spinal  cord.  It  often  contains  the  spinal  cord  itself  or  large 
nerve  trunks  (Bryant  and  Sayre). 

Characters  of  the  Tumors. — The  spinal  hernia  is  sometimes 
covered  by  the  whole  thickness  of  integument;  at  others  the  in- 
tegument, though  present,  is  very  thin;  while  occasionally  the 
walls  are  rejDresented  only  by  a  transparent  membrane.  The 
tumor  may  have  a  broad  base  and  free  communication  with    the 


516  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

central  canal  of  the  cord,  or  a  narrow  and  more  or  less  peduncu- 
lated one.  The  cord  is  more  likely  to  be  involved  in  the  greater 
than  in  the  less  base.  The  tumor  is  always  more  or  less  globu- 
lar, tense  and  elastic.  When  the  child  is  asleep  or  quiet  the 
swelling  may  be  soft;  but  when  the  child  cries  the  tumor  will 
rapidly  fill  out.  The  skin  of  the  tumor  may  be  ulcerated  at 
birth  or  have  a  small  opening  (Bryant). 

Associated  with  Hydrocephalus. — The  tumor  is  often  asso- 
ciated with  hydrocephalus  and  in  exceptional  instances  is  double. 
A  ncevus  is  not  seldom  found  situated  over  the  tumor.  Club- 
foot or  paralysis  of  the  lower  limbs  frequently  co- exist  with  it, 
and  in  these  cases  it  is  tolerably  certain  that  the  cord  is  included 
in  the  hernia.  Paralytic  symptoms  are  more  common  in  the 
broad- based  hernia  than  in  the  narrow.  Incontinence  of  urine 
or  of  feces  may  co- exist  with  the  paralysis  (Bryant). 

Situation  of  Tumor. — The  lumbo-  sacral  portion  of  the  column 
is  more  frequently  affected  than  any  other,  but  the  cervical  and 
dorsal  portions  are  also  liable  to  the  defect.  Of  twenty -seven 
cases  of  Bryant's,  thirteen  occurecl  in  the  lumbar  region,  four  in 
the  lumbo-sacral,  and  nine  in  the  sacral,  and  one  was  double,  a 
small  tumor  being  in  the  lumbar  and  a  large  one  in  the  sacral 
region.  Twelve  of  these  cases  were  uncomplicated  with  any 
paralysis  or  deformity.  In  eleven  there  was  incontinence  of 
urine  and  feces,  associated  in  four  with  paralysis  of  the  lower  ex- 
tremities. Four  were  complicated  with  hydrocephalus,  two  with 
naevus,  and  one  with  talipes.  Bryant  has  seen  but  two  cases  in 
which  the  tumor  was  in  the  cervical  region.  In  exceptional  cases 
the  spinal  hernia  may  protrude  on  the  anterior  part  of  the  spine. 
When  the  tumor  is  complicated  with  hydrocephalus  "fluctuation 
may  often  be  felt  between  the  two  parts,  pressure  on  the  head 
causing  a  fullness  of  the  spinal  hernia,  and  vice  versa  (Bryant). 
Diagnosis. — In  general,  there  is  no  difficulty  in  diagnosing  a 
spina  bifida.  In  any  infant  a  congenital  tumor  over  the  spine 
is  probably  a  spina  bifida;  if  globular  and  tense  or  capable  of 
becoming  tense  when  the  child  cries,  the  probabilities  are  almost 
converted  into  a  certainty.  The  only  cases  for  which  spina  bifida 
is  liable  to  be  mistaken  are  congenital  tumors,  unconnected  with 
the  spine,  such  as  cystic,  fibrous,  fatty  or    fcetal    tumors.     These 


SPINA    BIFIDA.  517 

may  be  hard  and  tense,  but  they  are  rarely,  if  ever,  made  so 
much  more  tense  from  the  child  crying,  as  is  the  spinal  hernia 
(Bryant). 

Prognosis. — The  majority  of  these  cases  prove  fatal.  Many 
of  the  subjects  are  ill -developed  and  die  within  a  few  days  of 
birth;  death  from  convulsions  is  very  usual  when  the  sac  bursts 
and  its  fluid  contents  escape,  more  particularly  when  the  escape 
is  rapid.  The  rupture  of  the  sac  is  not  necessarily  followed  by  a 
fatal  result.  Bryant  had  a  case  in  which  at  birth  the  tumor  was 
transparent  and  soon  burst,  and  subsequently  discharged  at  inter- 
vals for  three  years,  and  finally  contracted  up  into  a  solid  mass. 
This  case  is  an  example  of  a  natural  cure  by  gradual  closure  of 
the  bony  orifice.  The  more  pedunculated  the  tumor  the  better 
the  prognosis  (Bryant). 

Treatment. — The  treatment  of  these  cases  is  very  unsatisfac- 
tory. In  the  majority  of  cases,  palliative  treatment  is  all  that 
can  be  adopted;  although  in  exceptional  instances  operative 
interference  promises  to  be  of  service.  The  tumor  must  always 
be  guarded  from  injury  by  some  soft  protective  material.  Slight 
pressure  to  prevent  rapid  increase  of  the  tumor  is  always  bene- 
ficial. The  application  of  collodion  is  sometimes  useful.  Aspira- 
tion, subcutaneous  puncture  with  a  trocar,  and  injection  of  the 
iodo- glycerine  solution  have  been  practiced  with  more  or  less 
success.  Successful  cases  are  recorded  in  which  tapping  of  the 
hernia  has  been  performed.  The  practice  is  dangerous,  as  the 
drawing  off  of  the  fluid  has  been  followed  by  convulsions  and 
even  death;  yet  it  is  the  least  dangerous  form  of  practice,  and  may 
be  undertaken.  The  puncture  should  always  be  made  at  the  side 
of  the  tumor,  and  the  whole  of  the  fluid  should  never  be  drawn 
off  at  once. 

Mr.  W.  E.  Image,  of  Bury  St.  Edmund's,  cured  a  case  by 
puncture  with  a  darning-needle  at  intervals  of  two  or  three  days, 
four  or  six  times,  and  applied  a  compress.  In  this  case  con- 
vulsions were  produced  whenever  any  pressure  was  applied  to 
the  tumor,  but  ceased  after  tapping.  Dr.  Morton,  of  Glasgow, 
lias  advocated  the  injection  at  intervals  of  seven  or  ten  days  of 
half  a  drachm  of  a  solution  made  by  dissolving  ten  grains  of 
iodine  and  thirty  grains  of  iodide  of  potassium   in  an  ounce  of 


51 S  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

glycerine.  The  injection  should  be  thrown  into  the  sac  after  the 
withdrawal  of  a  small  portion  of  the  spinal  fluid.  Dr.  Morton 
reports,  in  1881,  that  out  of  twenty-nine  cases  operated  upon, 
there  were  but  six  failures.  This  success  is  encouraging.  In  a 
case  of  Bryant's,  after  the  second  tapping,  there  was  so  much 
draining  of  the""  fluid  from  the  cord  that  the  child  died  from  ex- 
haustion. 

In  no  case  where  the  base  or  neck  of  the  tumor  is  large  or 
the  cord  involved  should  this  or  any  other  operation  be  per- 
formed. In  pedunculated  tumors  an  operation  may  be  attempt- 
ed. In  the  case  of  a  tumor  with  a  small  pedicle  Dr.  Sayre  ligated 
the  base  of  the  sac  with  success.  He  passed  a  needle  armed  with 
a  double  ligature  through  the  centre  of  the  pedicle  and  after 
tying  one  ligature  on  each  side,  passed  two  circles  entirely 
around  the  pedicle,  drawing  them  so  tight  as  to  strangulate  the 
mass  and  then  excised  it  with  one  stroke  of  the  knife.  On  the 
twenty-third  day  the  ligatures  came  away  leaving  the  wound 
entirely  healed.  Dr.  Wilson,  of  Clay  Cross,  reports  a  successful 
case  in  which  he  removed  the  tumor  five  days  after  the  closure 
of  its  neck  by  means  of  a  clamp.  In  some  cases  of  spina  bifida 
nature  effects  a  more  or  less  perfect  cure  by  closing  in  the  defec- 
tive portion  of  the  spinal  canal.  The  child  should  be  fed  upon 
the  most  nutritious  diet  with  the  administration  of  the  phos- 
phates, lime,  etc.  (Bryant  and  Sayre). 

SPRAINS. 

May  be  very  slight  or  very  serious  indirect  injuries.  They 
include  more  or  less  severe  overstretchings,  if  not  lacerations  of 
the  muscles  or  ligaments  that  bind  the  bones  of  an  articulation 
together,  some  fracture  or  tearing  away  of  the  bone  at  the  attach - 
meut  of  the  ligaments — "sprain  fractures."  In  children  under 
ten,  sprains  of  joints  are  liable  to  be  complicated  with  some 
epiphysial  separation.  In  the  more  severe  instances  are  included 
lacerations  of  the  muscles,  tendons,  and  soft  parts  that  surround 
the  joint.  All  such  accidents  require  rest  and  time  in  their  treat- 
ment in  order  that  repair  may  be  complete,  since  neglected 
sprains  are  often  the  cause  of  joint  or  bone  disease  (Bryant). 


SPKAINS.  519 

Contusions  of  joints  as  direct  injuries  always  ought  to  be 
regarded  in  a  serious  aspect,  for  a  large  amount  of  internal  mis- 
chief may  often  be  sustained  with  very  slight  external  evidence 
of  injury.  Under  certain  conditions  of  health  a  slight  blow 
uj3on  a  bone  is  often  enough  to  set  up  severe  local  action  or  to 
excite  chronic  changes  which  may  involve  the  integrity  of  the 
joint  (Bryant). 

Sprain  of  the  hack  is  an  accident  of  common  occurrence. 
Any  twist  of  the  spine  or  forcible  flexion  may  injure  some  of  the 
joints.  Hemorrhage  may  take  place  iuto  the  spinal  canal  as  a 
result  of  the  sprain  or  laceration  of  the  ligaments. 

Prognosis. — Sprains  may  be  followed  by  acute  or  chronic 
joint  disease  of  a  serious  and  insidious  nature;  and  this  truth 
should  ever  be  before  the  surgeon  to  influence  his  practice.  In 
every  case  of  wounded  joint,  however  trivial,  and  in  all  doubtful 
cases  of  wounded  joint,  the  prognosis  must  be  very  guarded  and 
the  treatment  cautious  (Bryant). 

Treatment. — About  one  hundred  years  ago  John  Hunter 
said:  "In  sprains  of  joints  rest  is  the  first  'principle!'''  At  the 
present  day  the  same  words  are  as  pregnant  with  truth  as  when 
then  spoken.  In  simple  cases  of  sprain  rest  is  all  that  is  needed. 
When  swelling  and  effusion  into  the  joint  ensue  in  the  course  of 
the  second  or  third  day  after  the  accident,  the  evidence  of  inter- 
nal injury  is  more  marked,  for  such  effusion  means  inflammation 
or  synovitis,  which  is  to  be  treated  by  absolute  rest,  ensured  by 
the  application  of  a  splint,  and  the  local  use  of  cold  or  warmth. 
If  swelling  of  the  articulation  follows  immediately  upon  the 
injury,  effusion  of  blood  into  the  joint  is  indicated  with  or  with- 
out fracture,  but  always  with  severe  local  mischief.  Such  cases 
should  be  treated  by  the  employment  of  a  splint,  to  ensure  im- 
mobility of  the  joint,  elevation  of  the  injured  part,  and  local  ap- 
plication of  a  bag  of  pounded  ice  until  hemorrhage  has  ceased, 
and  all  risks  of  inflammation  of  the  joint  are  gone.  As  soon  as 
the  primary  effects  of  the  sprain  and  all  signs  of  inflammation 
have  passed,  the  application  of  pressure  to  the  joint  by  means  of 
a  bandage  with  passive  movement  is  very  striking.  When  the 
joint  is  rendered  very  tense  from  effused  blood,  it  may  be  asjnr- 
ated.    In  children  all  falls  upon  the  hip  followed  by  pain  should 


520  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

be  treated  by  rest  and  extreme  care,  as  hip  disease  may  originate 
from  such  cause  (Bryant). 

After  Treatment. — When  the  immediate  effects  of  the  sprain 
have  passed  away  the  local  use  of  a  stimulating  liniment  and 
moderate  friction  of  the  part  expedites  the  cure.  A  local  warm 
bath  at  intervals  likewise  relieves  the  stiffness  of  the  joint. 
Whenever  movement  excites  more  than  a  momentary  pain,  rest 
should  be  observed.  When  weakness  of  the  joint  alone  remains, 
a  good  bandage  or  strapping  around  the  part  to  give  support  is 
of  great  benefit.  Where  much  laceration  of  ligament  has  taken 
place  it  is  necessary  for  the  joint  to  have  some  artificial  support 
in  the  form  of  either  a  splint,  felt,  leather  casing  or  bandage; 
for  no  parts  are  repaired  with  less  permanent  power  than  liga- 
ments. In  the  wrist  when  much  swelling  exists,  a  sprain  may  be 
mistaken  for  a  fracture  or  a  fracture  for  a  sprain.  Much  care  is 
necessary  in  the  diagnosis  of  such  cases.  Many  sprains  of  the 
ankle  are  also  really  cases  of  fracture  of  the  fibula  above  the 
malleolus.  The  popular  notion  that  a  severe  sprain  is  worse  than  a 
fracture  is  in  the  main  true;  and  when  the  sprain  is  neglected 
the  case  is  always  more  tedious  than  that  of  a  broken  bone 
(Bryant). 

STRICTURE  OF  THE  URETHRA. 

An  unnatural  narrowness  of  any  portion  of  the  canal  of  the 
urethra  constitutes  stricture.  This  contraction  of  the  canal  to 
constitute  stricture  must  be  unnatural,  for  the  urethra  has 
certain  points  of  normal  contraction — namely,  the  meatus,  the 
middle  of  the  pendulous,  and  the  beginning  of  the  membranous 
urethra,  and  these  are  not  strictures.  They  become  so,  if  they 
are  unduly  small.  Thus,  an  individual  may  have  a  congenital 
stricture  of  the  meatus.  Any  inflammatory  condition  of  the  walls 
of  the  canal,  or  spasmodic  contraction  of  the  same,  constitutes 
stricture,  as  does  also  any  growth  upon  or  beneath  the  mucous 
membrane,  as  cancerous,  tubercular,  syphilitic  and  membranous 
(Keyes). 

Varieties  of  Stricture. — Stricture  is  of  two  kinds :  1.  Mus- 
cular, or  spasmodic.  2.  Permanent,  or  organic — the  latter  may 
be    congenital,   or    acquired.     Inflammatory   stricture    does    not 


STRICTURE    OF    THE    URETHRA.  521 

exist  as  a  disease  of  the  urethra.  No  amount  of  simple  inflam- 
mation of  the  urethra  would  occasion  serious  inconvenience 
(retention),  unless  occurring  in  connection  with  organic  stric- 
ture, assisted  by  muscular  spasm  or  complicated  by  prostatic 
congestion. 

I.  Muscular  or  Spasmodic  Stricture. — -Is  of  the  commonest 
occurrence;  an  active  predisposing  cause  is  a  sensitive,  high- 
strung  nervous  organization.  The  exciting,  causes  are  any  local 
irritation,  inflammation,  foreign  body,  irritation  of  the  rectum, 
(reflex  action),  ingestion  of  certain  substances,  as  cantharides, 
turpentine,  quinine,  opium,  etc.,  mental  emotions,  and  malaria. 
Take  a  nervous,  excitable  young  man  with  a  healthy  urethra,  or 
better  still  with  an  irritable  bladder  or  inflamed  urethra,  and 
attempt  to  pass  a  bougie  for  the  first  time,  and  the  chances  are 
that  it  will  be  arrested.  It  may  be  grasped  and  firmly  held  at 
any  part  of  the  canal,  but  this  is  more  liable  to  occur  just  as  the 
instrument  is  entering  the  membranous  urethra,  where  its  point 
may  be  detained  for  many  minutes  by  an  involuntary  contraction 
of  the  cut-off  muscles.  If  the  end  of  the  sound  is  held  quietly 
for  a  few  moments  against  the  contracting  muscle,  the  spasm  will 
yield,  and  the  instrument  pass  on  into  the  bladder. 

What  surgeon  has  not  witnessed  spasmodic  stricture,  caused 
by  modesty,  shame,  anxiety,  fear,  and  irritated  mind,  as  shown 
by  the  total  inability  of  some  patients  to  pass  water  before  a 
class  of  students  or  even  in  the  presence  of  a.  physician  alone  in 
his  office?  In  such  cases  there  is  a  failure  of  the  compressor 
urethrse  to  relax.  The  patient  contracts  his  abdominal  muscles 
and  his  diaphragm,  and  uses  all  his  will,  but  to  no  purpose. 
There  are  two  cases  on  record  of  malarial  spasm  where  s23asmodic 
stricture  occurred  paroxysmally  every  twenty -four  or  forty - 
eight  hours,  and  was  cured  by  quinine  after  other  means  had 
failed. 

Irritation  and  reflex  action  of  neighboring  parts,  as  inflamed 
hemorrhoids,  ulcer  or  worms  may  cause  spasmodic  stricture  and 
retention.  Thompson  gives  a  case  where  all  the  symptoms  of 
stricture  existed,  and  where  a  diagnosis  of  stricture  of  the  mem- 
branous urethra  was  made,  when  it  was  discovered  that  the 
patient  had   tapeworm.     After  the  worm  had  been   discharged, 


522  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  stricture  disappeared.  Necrosed  coccyx  and  abscess  of  the 
right  seminal  vesicle  have  caused  spasmodic  stricture.  Keyes 
saw  complete  retention  from  one  application  of  the  tincture  of 
delphinium  to  the  scrotum  to  destroy  pediculi.  Remote  surgical 
lesions  may  occasion  retention  by  reflex  spasmodic  stricture.  Dr. 
Davenport  records  the  case  of  an  old  man  who  had  all  the  evi- 
dences of  permanent  deep  urethral  obstruction  for  ten  years,  and 
who  was  relieved  at  once  and  permanently  by  a  single  passage 
of  a  silver  catheter.  Keyes  has  met  a  large  number  of  cases  in 
which  reflex  spasmodic  stricture  was  caused  by  a  decidedly 
narrow  meatus,  by  a  very  moderate  organic  stricture,  by  changes 
in  the  seminal  vesicles,  prostate,  bladder,  kidney,  and  strongly 
concentrated  acid  urine  (Keyes). 

Diagnosis. — Spasmodic  stricture  always  occurs  suddenly,  the 
stream  of  urine  between  the  paroxysms  being  of  normal  size.  It 
is  occasionally  continuous,  and  acts  exactly  like  organic  stricture 
(Keyes). 

Treatment. — Discover  and  remove  the  cause.  Retention  pro- 
duced by  simple  spasm  can  often  be  relieved  by  the  hot  bath, 
rest,  an  opiate,  and  ice  in  the  rectum,  or  at  once  by  an  anaesthetic 
and  the  catheter  (Keyes). 

II.  Permanent  or  Organic  Stricture. — If  not  congenital, 
is  the  result  of  a  previous  pathological  process. 

Form  of  Stricture. — 1.  Linear.  2.  Annular.  3.  Tortuous. 
A  linear  stricture  is  like  what  would  be  caused  if  a  thread  were 
tied  around  the  canal;  or  it  may  consist  of  a  thin  membranous 
diaphragm,  with  its  orifice  at  the  centre  or  on  one  side;  or  be  a 
crescentic  fold  or  free  band.  An  annular  stricture  is  broader, 
as  if  a  flat  tape  had  been  tied  around  the  canal.  Tortuous  stric- 
tures include  all  other  varieties.  They  may  be  an  inch  or  more 
long.  The  amount  of  contraction  in  stricture  varies  from  a  slight 
narrowing  to  nearly  absolute  occlusion  (Keyes). 

Number  of  Strictures.— Stricture  is  usually  single;  but 
Thompson  found  in  a  single  urethra,  four;  Hunter,  six;  Lalle- 
mand,  seven;  Colot,  eight;  and  Otis  fourteen  (Keyes). 

Seat  of  Stricture. — The  urethra  is  divided  into  three  regions: 
Ilegion  one,  the  bulbo-membranous,  contained  215  strictures  out 
of  a  total  of  320,  or  67  per  cent.;  region  two,  the  middle  portion, 


STRICTURE    OF    THE    URETHRA.  523 

contained  51  strictures,  or  16  per  cent.;  region  three,  the  first  two 
and  one-half  inches  of  the  canal  from  the  meatus,  contained  54, 
or  17  per  cent.  (Thompson).  Otis  places  a  majority  of  all  stric- 
tures within  the  first  one  and  one-quarter  inch  from  the  meatus; 
next  the  middle  portion,  and  the  least  number  in  the  deep 
urethra  (Keyes). 

The  Lesion  in  Stricture. — May  be  a  mere  thickening  of  the 
mucous  membrane,  the  surface  having  lost  its  polish,  being  con- 
gested and  perhaps  covered  with  granulations.  These  changes 
are  the  result  of  chronic  inflammation.  This  process  takes  place 
just  within  and  beneath  the  mucous  membrane.  If  the  stricture 
is  extensive  and  far  advanced  there  will  be  a  mass  of  dense, 
fibrous  callous  material  encircling  the  canal  and  holding  it  per- 
manently contracted.  This  tissue  may  be  slight  in  extent,  cicatri- 
cial in  character  and  tightly  contracted,  or  it  may  be  exuberant, 
knobbed  and  excessive  in  amount  so  that  it  may  be  readily  felt 
from  the  outside  of  the  canal,  having  a  cartilaginous  or  even 
woody  hardness  (Keyes). 

Causes  of  Stricture. — Omitting  congenital  and  other  varieties 
of  stricture  already  alluded  to  (cancerous,  etc.)  organic  stricture 
is  always  caused  by  inflammation  or  a  traumatism.  Inflamma- 
tion of  the  urethra  is  the  most  common  cause,  whether  this  be  sim- 
ple urethritis  or  gonorrhoea.  Of  220  cases  of  stricture  studied 
critically  by  Thompson  164  (seventy-five  per  cent.)  owed  their 
origin  to  gonorrhea.  The  longer  the  duration  of  a  given  gon- 
orrhoea the  more  certain  it  is  to  be  followed  by  stricture.  This 
is  almost  surely  the  case  where  gonorrhoea  prolongs  itself  in- 
definitely in  the  gleety  stage,  the  latter  condition  being  nearly 
conclusive  proof  of  forming  stricture.  Gonorrhoea  attended  by 
chordee  is  more  apt  to  be  followed  by  stricture  than  otherwise. 
Should  the  chordee  be  "broken,11  stricture  becomes  inevitable 
and  that  too  of  the  traumatic  sort.  The  new  fibroid  and  cicatri- 
cial tissue  has  a  tendency  to  contract  more  and  more,  jpraumatic 
stricture  may  be  produced  by  falling  astraddle  a  beam,  chair, 
stump,  fence  or  wheel,  or  a  kick  in  the  perinseum  from  man  or 
beast. 

The  only  treatment  of  gonorrhoea  which  may  cause  stricture 
is  the  use    of    injections.     The    nozzle    of  a  syringe,    if  long  or 


524  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

roughly  used  against  an  inflamed  mucous  membrane,  may  irritate 
it  sufficiently  to  keep  up  local  inflammation,  until  it  becomes 
chronic,  and  passes  on  to  that  cell -proliferation  and  thickening 
which  constitute  stricture.  Too  strong  injections  may  cause  strict- 
ure, usually  situated  from  two  to  four  inches  down  the  canal, 
rarely  lower.  As  a  general  rule,  it  may  be  stated  that  any  in- 
jection strong  enough  to  produce  either  blood  or  subsequent 
prolonged  pain,  is  capable  also  of  originating  organic  stricture 
(Keyes). 

Time  of  Occurrence  of  Stricture  after  Gonorrhoea  and  In- 
jury.— Of  the  one  hundred  and  sixty-four  cases  of  stricture  fol- 
lowing gonorrhoea,  tabulated  by  Thompson,  in  ten,  symptoms 
appeared  immediately  after  or  during  the  attack;  seventy -one 
within  one  year;  forty-one,  between  three  and  four  years;  twenty- 
two,  between  seven  and  eight  years;  twenty,  between  eight  and 
twenty-five  years.  J.  D.  Hill  makes  the  shortest  period  of  strict- 
ure after  gonorrhcea  two  years;  longest,  thirteen  years;  after  in- 
jury, shortest  period  four  months,  longest,  eighteen  months. 
Boys  have  been  kicked  at  school  or  have  fallen  on  a  fence,  and 
symptoms  of  stricture  did  not  occur  for  ten  or  twelve  years  after 
(Keyes). 

Irritable  and  Resilient  Strictures. — A  stricture  is  said  to  be 
irritable  when  it  is  very  sensitive.  A  resilient  stricture  is  one 
which  is  elastic,  contracting  quickly  after  being  dilated  (Keyes). 

Diagnosis. — Organic  stricture  of  the  urethra  is  easy  of  diag- 
nosis. In  exploring  a  given  urethra  for  the  first  time  for 
stricture,  Keyes  prefers  to  use  a  blunt  steel  sound  which  will 
just  pass  the  meatus.  The  blunt  sound  causes  less  pain  than 
either  the  bulbous  bougie  or  the  urethrameter.  It  should  be 
warmed,  lubricated,  and  introduced  with  all  gentleness.  If  it  is 
obstructed  anywhere,  there  is  stricture,  for  the  meatus  is  nor- 
mally the  smallest  part  of  the  canal.  When  an  obstruction  is 
encountered,  a  smaller  blunt  sound  is  selected,  and  then  another, 
until  some  sound  will  enter  the  bladder.  It  is  always  well  in 
searching  for  stricture  to  commence  with  a  large  size  and  work 
down  rather  than  to  begin  with  a  small  instrument. 

Keyes  has  had  cases  referred  to  him,  as  cases  in  which  a 
filiform  instrument  could  not  be  made  to  enter  the  bladder,  and 


STKICTURE    OF    THE    UEETHEA.  525 

he  has  at  once  passed  a  full- sized  blunt  steel  sound  easily  into 
the  bladder.  The  explanation  of  this  is  that  spasm  of  the  deep 
urethra  frequently  fails  to  allow  a  fine  instrument  to  pass,  while 
srjasin  in  that  region  always  yields  to  gentle  pressure  slowly  and 
accurately  applied  with  a  blunt  steel  sound.  Moreover,  a  false 
passage,  or  a  pouched  sinus,  or  a  dilated  follicle,  will  frequently 
catch  the  point  of  a  fine  instrument,  while  a  blunt  sound  will 
escape  the  obstacle.  Having  detected  stricture,  it  may  be 
located,  calibrated  and  measured  either  with  a  metallic  bulbous 
bougie  or  the  urethrameter  in  the  anterior  urethra,  or  with  a 
flexible  bulbous  bougie  in  the  deep  urethra.  Obstructions 
beyond  six  and  a  half  inches  may  generally  be  set  down  as  due  , 
to  prostatic  enlargement,  particularly  in  patients  older  than  fifty 
years. 

There  is  a  point  of  physiological  narrowing  at  about  the 
middle  of  the  pendulous  urethra,  which  is  by  some  regarded  as 
a  stricture  requiring  treatment  by  cutting,  when  there  is  no  real 
occasion  for  the  operation.  If  this  point  be  covered  by  granula- 
tions, and  bleeds  as  the  bulb  passes  it,  it  is  in  a  morbid  condi- 
tion, and  may  require  cutting,  although  no  true  stricture  exists 
at  the  point.  These  are  the  so-called  strictures  of  large  caliber 
so  popular  at  the  present  day,  so  common  in  occurrence,  a  rich 
field  for  the  young  surgeon,  and  sometimes  the  occasion  of  un- 
necessary cutting,  for  the  gleet  they  occasion  may  often  be 
removed  permanently  by  a  few  passages  of  a  large  sound.  Just 
within  the  meatus — at  an  eighth  to  a  quarter  of  an  inch — there 
is  very  often  a  point  of  congenital  narrowing  which  may  be 
assumed  to  be  a  stricture,  and  cut  if  there  is  any  occasion  for 
using  an  instrument  larger  than  this  point  of  narrowing  will 
admit.  It  is  always  wise  to  divide  it  if  stricture  exists  beyond. 
Always  when  there  is  a  pouched  condition  of  the  meatus  at  the 
lower  commissure,  it  should  be  cleanly  and  freely  cut  down  upon 
the  floor  of  the  urethra  (Keyes). 

Symptoms  and  Results  of  Stricture. — Stricture  may  exist  for 
years  without  giving  rise  to  a  single  symptom  of  sufficient  im- 
portance to  attract  the  patient's  attention.  In  fact,  it  may  be 
said  that  stricture  has  no  symptoms  until  it  has  become  so  tight 
as  to  sensibly  obstruct  the  outflow  of  urine  and  semen. 


526  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

The  symptoms  usually  described  as  those  of  stricture  are 
mainly  the  symptoms  of  the  results  of  stricture.  A  certain  small 
amount  of  gleety  discharge  from  the  congested,  or  it  may  be 
granular  surface  usually  accompanies  the  forming  stage  of  strict- 
ure but  this  may  be  so  slight  as  not  to  attract  attention  or  may 
be  entirely  absent.  Exceptionally  urethral  or  other  neuralgia 
depends  upon  stricture  in  the  forming  stage. 

The  results  of  stricture  are  mainly  mechanical.  The  strict- 
ured  portion  acts  like  a  dam,  and  the  urine  coming  down  with 
great  force  tends  to  dilate  the  urethra  behind  it.  If  more  than 
one  stricture  exists  the  urethra  may  be  dilated  between  them. 
This  forcible  stretching  of  the  mucous  membrane  behind  the 
stricture  at  every  act  of  micturition  weakens  the  tone  of  the 
stretched  portion  of  the  canal,  congests  it,  and  leads  to  the  for- 
mation locally  of  an  excess  of  mucus.  Soon  a  drop  of  urine  is 
retained  behind  the  stricture  in  the  dilated  portion  of  the  canal, 
the  mucus  acting  upon  it  as  a  ferment  alkalinizes  and  decom- 
poses it,  liberating  carbonate  of  ammonia.  This  acts  upon  the 
stretched  urethra,  and  produces  inflammation.  This  mild  in- 
flammation behind  stricture  is  very  constant.  It  furnishes  the 
gleety  discharge  or  the  morning  drop  of  muco-pus,  which  glues 
the  lips  of  the  meatus  together. 

The  gleet  of  stricture  gets  better  or  worse  according  to  the 
general  condition  of  the  patient,  the  degree  of  acidity  of  the 
urine,  and  the  amount  of  sexual  indulgence  or  venereal  excite- 
ment. Exacerbations  of  gleet  from  slight  causes  often  constitute 
the  most  marked  feature  of  the  case  in  a  patient  with  stricture. 
In  fact,  it  is  the  rule  in  mild  cases  that  the  patient  is  wholly  un- 
conscious that  his  urethra  is  at  all  narrowed.  He  applies  for 
treatment,  on  account  of  his  gleet,  and  often  refuses  to  believe  that 
he  has  stricture,  and  he  repeatedly  asserts  that  he  makes  as  large 
a  stream  of  urine  as  ever.  Nothing  so  well  as  the  bulbous  bougie 
will  convince  such  a  patient  of  his  condition.  The  gleety  dis- 
charge, once  commenced  behind  the  stricture,  rarely  ceases  en- 
tirely until  the  constriction  has  been  relieved.  The  same  dis- 
charge will  be  seen  in  the  urine  in  the  shape  of  small  stringy 
shreds,  formed  of  pus -corpuscles,  and  appear  as  small  white 
threads  in  the  voided  urine.     These  shreds  may  be  all  caught  in 


STRICTURE    OF    THE    URETHRA.  527 

the  first  gush  of  urine,  what  follows  being  perfectly  free  from 
them.  When  these  white  filaments  are  seen  settling  clown  in  a 
glass  of  urine  freshly  passed,  they  constitute  strong  presumptive 
evidence  of  the  existence  of  stricture;  they  may  he  due  to  other 
lesions.  As  the  stricture  tightens,  a  cartilaginous  hardness  may 
often  be  felt  from  the  outside  of  the  urethra  at  the  constricted  point. 
The  meatus  urinarius  looks  blue  and  congested,  as  does  some- 
times the  whole  glans  penis,  from  obstructed  circulation.  The 
gleet  continues,  the  stream  of  urine  is  small,  often  forked.  The 
last  few  drops  of  urine  are  retained  in  the  canal.  Erection  is 
sometimes  rendered  imperfect  and  painful. 

The  surface  congestion  of  the  stretched  urethra  behind  the 
stricture  in  time  extends  backward  to  the  bladder,  and  brings  on 
irritability  of  that  organ.  The  intervals  between  the  acts  of 
micturition  grow  shorter  and  shorter,  and  symptoms  of  mild 
cystitis  appear.  This  frequency  of  micturition  is  the  symptom 
of  stricture,  next  to  gleety  discharge,  which  is  least  often  absent. 
A  slight  narrowing  of  the  canal  may  occasion  it.  The  conges- 
tion of  the  urethra  behind  a  stricture  easily  becomes  greater,  is 
kindled  into  positive  inflammation  by  dining  out,  a  little  excess 
in  drink,  or  a  chilling  of  the  legs;  the  mucous  membrane  swells 
up,  the  stricture  closes,  and  the  patient  has  retention  of  urine. 
If  this  retention  is  unrelieved,  the  bladder  becomes  over-dis- 
tended and  the  contractile  power  of  the  bladder  may  be  perma- 
nently injured.  Retention  maybe  the  onlg  disagreeably  promi- 
nent symptom  connected  with  a  case  of  stricture.  The  spasm  and 
inflammation  which  caused  the  narrow  canal  to  become  oblite- 
rated in  these  cases,  cease  after  a  few  hours,  and  then  the  patient 
goes  on  perhaps  for  a  year  or  more,  without  having  another 
retention,  not  suffering  noticeably  in  the  meantime. 

If  retention  does  not  come  on,  the  inflammation,  once 
aroused  behind  the  stricture,  travels  back  through  the  prostatic 
urethra  into  the  bladder,  and  we  have  cystitis  of  the  neck.  No\\r 
commences  a  frequent  desire  to  pass  water,  and  when  the  patient 
seeks  relief,  he  may  be  passing  water  in  a  fine  stream  every  half- 
hour  with  great  pain  and  straining.  HcematwHa  maybe,  excep- 
tionally, the  most  prominent  symptom  of  stricture.     Keyes  has 


528  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

had  several  such,  cases,  and  has  seen  the  hematuria  cease  upon 
relieving  the  stricture. 

Along  with  symptoms  of  vesical  irritation,  are  found  pains 
in  the  urethra,  aching  of  the  glans  penis,  or  in  the  testicle,  along 
the  cord  running  up  into  the  back,  pains  across  the  lumbar 
region,  in  the  perinseuin,  around  the  anus,  over  the  pubis,  in  the 
thighs,  legs,  sole  of  the  foot,  or  in  the  great  toe,  all  of  which 
pains  are  cured  by  the  dilatation  of  the  stricture.  The  sexual 
appetite  is  often  impaired,  sometimes  nearly  obliterated,  in  old 
severe  cases.  But  in  mild  cases,  the  congestion  kept  up  behind 
the  stricture  may  be  just  enough  to  excite  and  irritate  the 
jDatient,  causing  frequent  erections,  erotic  fancies,  and  nocturnal 
emissions.  The  constant  straining  in  urination  may  cause  piles. 
The  inflammation  of  the  bladder  caused  by  stricture  is  usually 
superficial,  and  the  bladder  walls,  as  a  rule,  thicken  and  contract, 
but  rarely  dilate.  The  ureters  enlarge  in  connection  with  old 
stricture,  also  the  pelvis  of  the  kidney.  It  may  bring  on  abscess 
of  the  kidney  (Keyes). 

Extravasation. — The  thinned  and  inflamed  urethra  behind 
the  stricture  may  ulcerate  and  during  one  of  the  violent  parox- 
ysms of  straining  give  way  and  allow  a  little  urine  to  escape  into 
the  cellular  tissue  around  the  canal.  If  the  amount  of  urine 
extra vasated  is  small  we  have  abscess  or  perhaps  blind  internal 
fistula.  Its  presence  is  indicated  by  a  hard  lump  around  the 
urethra  from  the  size  of  a  pea  to  that  of  a  walnut.  Urethral  fe- 
ver comes  on,  generally  described  by  the  patient  as  "dumb 
ague;"  the  appetite  fails  and  the  general  health  runs  down, 
finally  pus  forms  and  finds  its  way  out  through  the  perinseuin, 
leaving  a  fistula  behind.  If  the  quantity  of  urine  which  escapes 
is  a  little  larger  acute  perineal  abscess  forms.  The  pus  may  bur- 
row in  all  directions  and  find  an  exit  through  the  scrotum  along 
the  body  of  the  jDenis,  upon  the  thighs,  nates  or  groins,  or  even 
upon  the  lower  part  of  the  abdomen.  Sometimes  the  whole 
perinseuin  is  riddled  with  holes  through  which  the  urine  escapes. 
Civiale  reports  a  case  of  urinary  fistula  with  fifty-two  external 
openings.  Fistula  will  not  close  until  after  the  stricture  has 
been  relieved.  Extravasated  urine  should  be  let  out  as  soon  as 
possible.     Normal  urine  does  not  possess  septic  qualities     but 


STRICTITEE    OF    THE    URETHRA.  529 

aruinoniacal  and  putrid  decomposing  urine  is  deadly  in  its  effect 
(Keyes). 

Complications  of  Stricture. — Infiltration  of  urine  is  a  serious 
complication.  Rupture  of  the  bladder  is  a  rare  complication  of 
stricture.  A  comparatively  healthy  bladder  will  not  rupture 
from  retention.  It  will  become  immensely  distended  and  then 
be  relieved  by  drops  (overflow)  through  the  urethra. 

Epididymitis  is  a  very  common  complication  of  stricture. 
It  may  affect  one  or  both  sides,  and  leaves  behind  a  good  deal  of 
knotty  induration,  which  is  slow  in  disappearing,  and  may  block 
up  the  canal  and  entail  subsequent  sterility  (Keyes). 

Constitutional  Disturbance. — A  patient  with  very  tight  stric- 
ture may  enjoy  robust  health.  But  when  the  urethra  behind  a 
stricture  begins  to  inflame,  and  the  bladder  to  show  symptoms 
of  congestion  of  the  neck,  and  cystitis;  when  paroxysms  of 
urethral  fever  become  frequent;  when  epididymitis  and  abscess 
come  on,  then  the  whole  organism  shows  signs  of  distress.  The 
a23petite  and  strength  fail,  the  skin  becomes  dry,  pale  and  harsh, 
the  mouth  coated  and  shiny,  and  the  patient  runs  down  to  a 
shadow,  a  living  picture  of  misery,  while  his  main  business  in 
life  is  to  pass  water  (Keyes). 

Causes  of  Death  in  Stricture  Cases. — Are  three: 

1.  Extravasation  of  u/rime,  which,  if  extensive  kills  at  once 
by  shock,  or  later  by  exhaustion  and  blood-poisoning  with  sup- 
puration, abscess,  gangrene  and  pyaemia. 

2.  Urcemia,  from  implication  of  the  kidneys,  by  the  exten- 
sion of  inflammation  up  the  ureters. 

3.  Cachexia  and  exhaustion  (Keyes). 

^Recapitulation  of  Symptoms  of  Stricture. — Briefly  the 
symptoms  of  stricture  are  narrowing  of  the  canal,  with  dilata- 
tion of  the  urethra  behind,  blueness  of  the  meatus,  irregularities 
in  the  stream  of  urine,  shreds  of  pus-corpuscles  in  the  urine, 
pain,  neuralgia  of  the  urethra,  retention  of  urine,  overflow, 
dribbling,  imperfect  erection,  irritability  of  the  bladder,  haema- 
turia,  and  impotence.  The  remoter  results  of  stricture  are 
cystitis  with  changes  in  the  bladder,  ureters,  kidneys  mid  rectum 
often  terminating  fatally,  and  stone  in    the   bladder,  infiltration, 


530  A    COMPENDIUM    OF    PRACTICAL     MEDICIJSTE. 

perineal  abscess,  fistula,  rupture  of  the  bladder,  epididymitis,  and 
sterility  (Keyes). 

Sexual  Hygiene. — An  unmarried  man  frequently  tortures 
himself  with  fancied  ailments,  which  he  ascribes  to  stricture.  He 
declares  himself  strictured  when  the  canal  is  sound.  Fancied 
stricture,  next  to  fancied  spermatorrhoea,  is  a  very  common  hypo- 
chondriacal expression  of  perverted  sexuality.  The  trouble  is  in 
the  mind.  These  patients  must  be  put  right  about  the  cause  of 
their  troubles,  and  their  sexual  hygiene  must  be  regulated.  This 
can  be  accomplished  only  by  marriage  or  by  purity  of  thought 
and  absolute  continence  (Keyes). 

Treatment. — May  be  considered  under  three  heads: 

1.  Treatment  of  Uncomplicated  Stricture. — («)  Of  large 
caliber;  (b)  of  small  caliber;  (<?)  of  the  meatus;  (d)  traumatic; 
(#)  resilient — often  irritable. 

2.  Treatment  of  Stricture  complicated  by — (#)  False  pas- 
sage; (b)  retention;  (c)  retention — the  stricture  being  impassa- 
ble; (d)  infiltration;  (<?)  abscess;  (/)  fistula;  (g)  pericystitis; 
(Ji)  enlarged  prostate. 

3.  Treatment  of  Fistula  with  Loss  of  Substance. — (a)  Of 
large  caliber. — The  majority  of  strictures  which  the  surgeon  is 
called  upon  to  treat  are  of  large  caliber.  The  symptom  of  which 
the  patient  complains  is  persistent  gleet  following  gonorrhoea,  or 
bastard  gonorrhoea,  with,  possibly,  some  frequency  in  urination. 
In  these  cases  the  gleet  is  treated,  and  the  stricture  overlooked. 
The  urethra  should  be  explored,  in  such  cases  of  gleet,  with  the 
bulbous  bougie.  One,  two  or  more  strictures  are  found.  The 
chances  of  urethral  chill,  after  first  examinations,  must  be  remem- 
bered. Being  instructed  not  to  mind  the  smarting  at  his  next 
urination,  and  given  an  alkali,  the  patient  is  dismissed  to  return 
in  two  days,  to  have  his  treatment  commenced.  The  treatment 
which  generally  gives  satisfaction  in  a  majority  of  these  cases  is 
dilatation  with  the  conical  steel  sound.  One  of  these  sounds 
warmed,  and  of  a  size  corresponding  to  the  bulbous  bougie, 
should  be  passed  with  the  utmost  delicacy  and  gentleness.  At 
the  strictured  and  tender  points  a  spasmodic  contraction  may 
occur,  arresting  the  instrument. 


STRICTURE    OF    THE    URETHRA.  531 

To  overcome  this  patience  is  better  than  force.  After  one 
sound  has  been  withdrawn  a  second  and  even  a  third  may  be  in- 
troduced, if  it  is  considered  safe.  The  tendency  is  always  to 
hurry  and  use  force  which  is  detrimental.  It  may  be  stated  as  a 
rule  that  if  a 'conical  steel  instrument  of  any  size  larger  than 
JVo.  15  will  not  enter  a  stricture  by  its  own  freight  after  a  little 
delay  when  held  in  proper 'position,  it  should  not  he  used.  If 
force  be  used  in  passing  sounds  the  injury  will  be  threefold:  1. 
The  production  of  epididymitis.  2.  The  excitement  of  inflam- 
mation in  the  stricture.  3.  The  production  of  chill  and  urethral 
fever.  The  patient  should  wear  a  suspensory  bandage  while  tak- 
ing this  treatment.  At  each  subsequent  visit  of  the  jDatient  the 
surgeon  commences  with  a  sound  from  one  to  two  sizes  smaller 
than  the  last  instrument  introduced  at  the  previous  visit  and  car- 
ries the  dilatation  as  far  as  possible  without  the  employment  of 
force — this  till  the  full  size  is  reached. 

Intervals  between  the  Sittings. — These  vary  in  different 
cases;  but  it  may  be  stated,  as  a  rule,  that  it  is  bad  surgery  in 
treating  stricture  by  dilatation  to  re-introduce  an  instrument — 
unless  it  be  filiform — before  the  lapse  of  at  least  seventy -two 
hours,  and  that  more  rapid  progress  will  be  made  with  the  case 
by  waiting  till  after  ninety -six  hours — often  even  until  the  sixth, 
seventh  or  eighth  day.  The  reason  for  this  rule  becomes  clear 
upon  studying  the  therapeutic  effect  of  pressure  upon  stricture - 
tissue.  The  first  effect  is  mechanical  (stretching)  and  sedative 
(quieting  muscular  spasm  at  the  strictured  point);  this  lasts 
twenty-four  hours.  The  next  effect  is  reactionary  (congestive 
and  spasmodic),  resulting  in  extra  tightness  of  the  stricture  and 
increase  of  discharge;  this  lasts  from  24  to  48  hours.  The  final 
curative  effect  is  absorptive.  Absorption  is  excited  by  the  in- 
creased activity  of  the  circulation  about  the  stricture,  and  con- 
tinues for  two  or  three  days  or  longer;  after  which,  contraction 
and  growth  of  stricture  -tissue  recommences.  It  is  just  at  the 
period  where  absorption  ceases  and  recontraction  commences  that 
a  dilating  instrument  can  be  reapplied  most  effectively,  and  this 
period  is,  in  the  majority  of  cases,  on  the  fifth  to  the  eighth  day. 
That  absorption  takes  place  during  the  cure  of  stricture  by 
dilatation  may  be  proved  during  life  by  examining  the  hard  car- 


582  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tilaginous  bands  often  found  surrounding  the  urethra,  and  con- 
stituting stricture.  These  bands  can  be  distinctly  felt,  over  an 
instrument  introduced  through  the  stricture,  and,  during  the 
treatment,  observed  to  become  smaller. 

As  to  the  degree  of  dilatation  which  is  to  be  aimed  at,  every 
urethra  has  its  ovrn  gauge  in  the  size  of  its  meatus — provided 
that  meatus  be  not  congenitally  small,  or  contracted  by  disease. 
If  there  is  any  cicatricial  tissue  in  the  circle  of  the  meatus,  or  if 
a  probe  can  make  out  any  pouching  below  the  lower  commissure, 
the  meatus  is  strictured,  and  requires  treatment.  The  normal 
meatus  is  the  smallest  part  of  the  healthy  canal,  and  the  object 
in  view  is  to  bring  all  available  pressure  to  bear  upon  a  morbid 
narrowing  of  some  other  portion  of  the  tube.  To  do  this  the 
meatus  must  be  put  lightly  upon  the  stretch.  The  meatus  may 
often  be  cut,  even  when  not  obviously  too  small,  in  order  to 
facilitate  the  use  of  a  sound  larger  than  would  otherwise  pass. 
Strictures  of  the  anterior  urethra,  if  very  freely  cut,  may  be  radi- 
cally cured;  not  so  strictures  of  the  deep  urethra.  The  latter 
require  the  use  of  dilating  instruments. 

The  size  to  which  a  strictured  uretha  may  be  dilated,  is  as- 
certained by  measuring  the  circumference  of  the  flaccid  penis; 
circumference  of  penis,  3  inches;  the  urethra  should  take  size  30. 
3^  inches;  size  32.  3i  inches;  size  34.  3f  inches;  size  36.  4 
inches;  size  38.  ±\  to  4i  inches;  size  40.  (Dr.  Otis's 
Standard). 

As  soon  as  a  full -sized  instrument  will  slip  through  a  stric- 
ture by  its  own  weight,  all  symptoms  will  usually  have  ceased: 
but  recontraction  will  almost  inevitably  take  place  in  stricture 
of  the  deep  urethra,  unless  the  sound  be  passed  weekly  or  fort- 
nightly for  a  long  time  (KeyesV 

{¥).  Of  Small  Caliber. — To  this  class  belong  strictures  ad- 
mitting any  instrument  less  than  No,  15.  This  class  of  strictures 
requires  the  same  kind  of  treatment  as  those  of  large  caliber, 
but  are  better  treated  with  soft  than  with  steel  instruments. 
There  is  danger  of  making  a  false  passage  in  an  obstructed 
urethra  with  a  small  metallic  instrument.  Below  Xo.  15,  soft 
instruments  only  should  be  employed,  unless  there  be  a  guide 
throuo-h  the  stricture.     Dilatation  is  carried  on  as  already  direct- 


STRICTURE    OF    THE    URETHRA.  533 

ed,  steel  instruments  being  used  as  soon  as  the  stricture  will  ad- 
mit No.  15.  Progress  is  slower  with  soft  than  with  steel  instru- 
ments. Cutting  (internal  urethrotomy)  and  stretching  (divulsion) 
operations  are  growing  daily  in  favor  in  the  treatment  of  strict- 
ures of  small  caliber,  yet  stricture  in  the  deep  urethra  is  best 
treated  by  dilatation,  no  matter  how  tight  it  may  be.  Cutting 
and  divulsion  are  only  helps.  They  are  attended  by  danger.  The 
sound  must  be  used  after  them.  The  patient  need  not  lose  a  day 
from  business  on  account  of  treatment  by  dilatation.  It  is  safer, 
and  more  tedious. 

Divulsion  or  internal  urethrotomy  may  be  better  in  two 
classes  of  cases:  1.  If  the  patient  cannot  give  time  enough  to 
carry  out  dilatation  properly.  2.  If  pretty  severe  urethral  fever 
follows  attempts  at  dilatation.  All  true  strictures  of  the  pen- 
dulous urethra  maybe  radically  cured  by  free  cutting  internally. 
Otis  proved  this.  Radical  cures  are  accomplished  by  free  cut- 
ting anteriorly — -not  so  in  the  deep  urethra.  In  commencing  the 
treatment  of  stricture  of  small  caliber,  it  may  be  impossible  to 
enter  the  bladder  with  any  instrument,  either  on  account  of  the 
tightness  of  the  stricture,  or  because  the  point  of  the  instrument 
does  not  engage  in  the  latter.  In  these  cases  gentle  perseverance 
and  skill  will  rarely  fail  of  success.  Keyes  mentions  one  case  of 
his  own  in  which  it  required  ten  sittings,  most  of  them  over  one 
hour  long,  before  any  instrument  could  be  made  to  enter  the 
bladder.  On  the  tenth  effort,  the  instrument  passed.  It  entered 
the  bladder,  and  at  once  the  stricture  was  divulsed.  In  two 
weeks  the  patient  passed  his  own  full-sized  instrument.  In  the 
so-called  impassable  stricture,  where  urine  passes  out,  but  no  in- 
strument can  be  made  to  enter  the  bladder,  a  filiform  bougie  can 
invariably,  with  patience,  be  inserted  into  the  orifice  of  the  stric- 
ture (Keyes). 

(c)  Stricture  of  the  Meatus. — Stricture  at  or  near  the 
meatus  is  usually  made  worse  by  attempts  at  dilatation,  ft  must 
be  cut. 

(d)  Traumatic  Strictures. — Are  not  usually  amenable  to 
treatment  by  dilatation. 

(<?)  Resilient  Strictures. — 'Will  not  dilate,  must  be  cut 
(Keyes).     Treatment  of  stricture  complicated  by— 


534  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

(a)  False  Passage. — Results  from  rough  or  unskillful  use 
of  small  instruments  in  an  obstructed  urethra.  On  the  with- 
drawal of  the  instrument,  blood  flows  freely  from  the  meatus. 
The  treatment  for  a  fresh  false  passage  of  this  sort  is  to  let  it 
alone  absolutely  for  two  weeks.  To  avoid  a  false  passage  of  any 
kind,  when  searching  for  the  orifice  of  a  narrow  stricture,  con- 
sists in  filling  the  urethra  with  whalebone  filiform  bougies,  thus 
mechanically  filling  up  the  false  passage,  until  some  instrument 
will  glide  by   its  orifice  and  enter  that  of  the  stricture. 

(b)  Retention. — A  patient,  with  stricture,  may  be  enjoy- 
ing good  health,  when  suddenly,  after  exposure  to  cold,  after  a 
dinner  or  a  carouse,  he  finds  that  he  can  not  pass  water.  If  no 
instrument  can  be  passed,  the  patient  should  be  placed  in  a  hot 
bath  for  15  or  20  minutes,  or  a  sitz-bath.  He  will  often  be  able 
to  pass  water  while  in  the  bath.  A  piece  of  ice  in  the  rectum 
may  be  tried.  A  grain  of  opium  may  be  given  every  hour  until 
four  or  five  doses  have  been  taken. 

(d  )  Infiltration  of  Urine. — The  infiltrated  urine  must  be 
drained  off,  and  the  stricture  relieved.  The  operative  indica- 
tions are  three  :  1.  To  stop  progressive  infiltration  by  extensive 
dependent  incisions.  2.  To  provide  an  escape  for  urine  con- 
stantly collecting  in  the  bladder,  by  free  central  incision  of  the 
urethra  behind  the  stricture.  3.  To  divide  the  stricture 
thoroughly. 

(e)     Abscess. — The  abscess  should  be  opened. 

(/)  Fistulas. — A  simple  fistula  with  one  or  two  openings 
will  close  of  itself,  as  soon  as  the  stricture  has  been  dilated  fully. 
In  all  these  cases  treat  the  stricture  first,  and  then  the  fitsulse.  If 
the  fistulse  remain  after  full  dilatation  of  the  urethra,  the  patient 
must  pass  no  urine  except  through  a  catheter  for  one  month.  If 
this  fail,  the  hard  edges  of  the  fistulous  tract  should  be  incised, 
or  cauterized  with  the  gal vano- cautery.  A  silver  probe  coated 
with  fused  nitrate  of  silver  may  be  passed  into  the  fistulse 
(Keyes). 

Instruments. — The  instruments  necessary  to  treat  all  cases  of 
stricture  are:  different  varieties  of  bougies,  sounds  and  catheters 
with  a  scale;  instruments  for  divulsion,  internal  and  external 
urethrotomy,  and  an  aspirator. 


STRICTURE    OF    THE    URETHRA.  535 

Bougies. — -Filiform  bougies  are  such  as  measure  one  milli- 
metre or  less  in  diameter.  There  are  three  varieties:  the  French, 
English,  and  whalebone.  The  whalebones  are  olive-tipped. 
Whalebone  filiform  bougies  have  displaced  all  others  at  the 
present  date.  These  bougies  may  be  used  as  guides  for  larger 
instruments,  if  made  about  two  feet  long.  In  employing  a 
whalebone  as  a  guide  it  should  be  first  introduced  into  the  blad- 
der then  threaded  into  the  instrument  to  be  guided.  In  intro- 
ducing a  filiform  bougie  when  it  catches,  partially  withdraw  and 
slightly  rotate  it,  pushing  it  forward  while  making  the  rotatory 
movement.  An  excellent  method  of  finding  the  orifice  of  a  strict- 
ure, especially  where  false  passage  exists,  consists  in  cramming 
the  urethra  full  of  filiform  bougies,  engaging  their  points  in  all 
the  lacunae  and  false  passages,  and  then  trying  them,  one  after 
another  until  one  is  pushed  through  the  stricture.  Injecting  the 
urethra  full  of  warm  oil  is  a  great  aid.  Of  the  other  bougies 
(not  filiform)  the  French  and  English  conical  are  used.  The 
French  conical  are  necessary  in  the  treatment  of  stricture  up  to 
size  12  or  15.  English  yellow  bougies  are  smoother  and  stiffer 
than  the  preceding.  All  of  the  foregoing  instruments  are  intro- . 
duced  without  a  stylet  by  simple  direct  pressure  with  rotation. 

The  Bulbous  Bougie. — Is  an  instrument  necessary  for  the 
accurate  diagnosis  of  stricture.  They  consist  of  a  "flexible,  woven 
shaft,  headed  by  an  acorn -shaped  extremity.  A  set  of  them, 
running  from  five  to  thirty,  is  required.  The  urethrameter  of 
Otis  was  designed  to  take  the  place  of  a  whole  set  of  bulbous 
bougies  from  size  twenty  to  forty. 

Sounds. — The  steel  sound  is  the  most  necessary  instrument 
for  the  treatment  of  stricture.  Steel  sounds  are  conical  or  blunt. 
The  conical  are  the  better  instruments  and  should  run  from  No. 
13  to  35,  inclusive.  For  dilating  stricture  soft  instruments  are 
better  in  the  low  sizes — below  No.  13,  and  steel  for  all  sizes 
above  No  13.  Thompson's  rapid  dilator  and  Otis'  dilating 
urethrotome  are  much  used  in  the  treatment  of  stricture  (Keyes). 


536  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

SPINAL  IRRITATION. 

Is  always  functional  and  in  most  cases  is  associated  with 
congestion  or  anaemia  (Loomis). 

Causes. — It  occurs  chiefly  in  women  between  the  ages  of  fif- 
teen and  twenty-five.  Spinal  shock,  or  concussion  from  any 
cause,  and  all  those  practices  and  habits  which  cause  nervous 
strain  and  result  in  nervous  exhaustion,  may  also  produce  spinal 
irritation.  Chronic  alcoholism  and  the  opium  habit  may  also 
induce  it.  All  severe  diseases  may  cause  it  (Loomis).  Anseinia 
of  the  posterior  columns  of  the  cord  is  a  cause  (Hammond). 

Symptoms. —  The  one  constant  and  special  symptom  of  spinal 
irritation  is  tenderness  all  along  the  cord  or  over  a  single  verte- 
bra, which  maybe  excited  by  pressure,  motion,  heat,  cold,  elec- 
tricity or  other  irritants.  The  spinous  process  is  the  place  where 
pressure  causes  greatest  pain.  Tactile  hyperesthesia  is  very 
marked.  Motor  disturbances  are  common.  Weariness,  and 
heaviness  occur  in  the  lower  limbs.  Contraction,  twitchings  and 
spasm  may  occur  in  the  muscles  of  the  forearm.  Cardiac  palpi- 
tation, nausea  and  vomiting,  nervous  cough,  embarrassed  phona- 
tion  and  breathing,  and  attacks  of  fainting  are  not  uncommon. 
Patients  are  depressed,  melancholy,  and  irritable,  and  subject  to 
insomnia,  headache,  dizziness,  etc.  Vaso-motor  changes  are 
marked;  the  extremities  are  cold,  sometimes  blue,  and  the  face 
alternately  pales  and  flushes.  When  the  point  of  tenderness  is 
in  the  cervical  region  the  pains  are  referred  to  the  head,  pharynx 
and  chest.  When  it  is  lower  there  are  respiratory  and  cardiac 
symptoms,  and  if  in  the  dorsal  region,  there  is  pain  in  the  stom- 
ach with  dyspepsia,  nausea  and  vomiting  (Loomis). 

Differential  Diagnosis. — Spinal  irritation  maybe  mistaken  for 
spinal  congestion,  meningitis,  myelitis,  tumors  and  tetany.  In 
spinal  congestion  there  is  no  tenderness,  and  the  symptoms  are 
aggravated  by  the  supine  position  ;  in  spinal  irritation  the 
reverse  is  the  case. 

Sjpinal  meningitis  is  accompanied  by  pyrexia,  and  the  pain 
in  the  spine  is  increased  by  motion,  and  muscular  spasms  occur 
in  the  back  and  neck.  The  iron  band  sensation  about  the  waist, 
paralyses,  etc.,   are    almost    diagnostic    of    myelitis.     In    spinal 


SPINAL    IRKITATIOX.  537 

tumors  the  symptoms  are  localized  and  permanent.  In  tetany 
there  are  muscular  contractions  (Loomis). 

Prognosis. — Is  favorable. 

Treatment. — Alcoholic  stimulants,  meat  diet  and  exposure  to 
sunlight  and  fresh  air  are  of  service.  Aconite  and  veratria  may 
be  applied  locally  in  the  form  of  an  ointment.  The  galvanic 
current  and  the  Faradic  current  in  some  cases  will  give  imme- 
diate relief.  The  daily  application  of  the  ice-poultice  is  recom- 
mended. Absolute  rest  in  the  country  with  a  good  diet  does 
much  for  these  patients  (Loomis). 

SNEEZING. 

Treatment. — Camphor  is  an  excellent  remedy  in  incessant 
sneezing  with  profuse  running  from  the  eyes  and  nose.  The 
powder  should  be  sniffed  or  the  alcoholic  solution  inhaled  from 
a  handkerchief.  One,  two  or  three  drops  of  Fowler's  solution 
three  times  a  day  are  very  efficacious  in  the  paroxysmal  sneezing 
allied  to  asthma.  In  ten -grain  doses  several  times  a  day  iodide 
of  potassium  is  said  to  cure  that  troublesome  and  obstinate  af- 
fection, violent  paroxysmal  sneezing  (Ringer). 

SOMNAMBULISM, 

Is  a  condition  incident  to  sleep.  It  embraces  the  mental  and 
physical  performances,  sometimes  very  extraordinary,  which  are 
observed  in  sleep-walkers.  Similar  phenomena  are  observed  in 
the  condition  known  as  the  hypnotic  or  mesmeric  or  magnetic 
sleep  (Flint). 

Treatment. — In  these  cases  bromide  of  potassium  is  probably 
the  best  remedy  if  given  in  large  doses  (Ringer). 

SORE  FEET. 

A  tablespoonful  of  common  washing  soda,  added  to  half  a 
gallon  of  warm  water,  is  useful  in  the  treatment  of  tenderness  of 
the  soles.  The  feet  should  be  immersed  for  half  an  hour  twice  a 
week  or  oftener  (Ringer). 


538  A    COMPENDIUM    OF    PKACTICAL     MEDICINE. 

STINGS. 

Insect -stings  in  the  United  States  are  not  very  severe,  and 
unless  inflicted  in  large  numbers  are  rarely  brought  under  the 
notice  of  physician  or  surgeon.  Slight  fever  and  constitutional 
disturbance  may  follow  them  in  children  who  are  very  suscepti- 
ble to  external  influences,  whilst  local  swelling,  heat,  and  red- 
ness are  very  marked  in  others.  Should  a  wasp  or  bee  acciden- 
tally be  taken  into  the  mouth  with  fruit  and  the  base  of  the 
tongue,  pharynx,  or  larynx  stung,  serious  symptoms  may  arise 
from  oedema  and  swelling  of  the  parts  impeding  respiration. 
AVhen  this  accident  happens,  scarifications  should  be  employed 
with  fomentations;  but  if  life  be  threatened,  the  wind- pipe  must 
be  opened. 

The  sting  should  be  removed,  if  possible,  with  forceps.  A 
drop  of  liquor  ammonia,  or  sal  volatile,  or  oil  of  lavender  ap- 
plied to  the  part  generally  gives  relief.  The  parts  should  be 
protected  from  the  air  by  collodion,  flour,  chalk  or  strapping. 

For  mosquito -bites  Dr.  J.  Stevenson  advises  the  use  of  a 
moist  cake  of  soap,  the  thin  lather  from  the  cake  being  allowed 
to  dry  upon  the  bitten  part.  All  pain  and  itching,  he  states, 
disappears  within  ten  minutes  of  this  application.  In  South 
America  the  mosquito -bite  is  at  times  attended  with  severe  local 
inflammation  and  sometimes  with  ulceration. 

In  Africa  and  Asia  the  scorpion,  which  is  from  six  to  ten 
inches  long,  is  so  venomous  as  to  cause  by  its  bite,  at  times,  loss 
of  life.  Olive  oil  is  the  usual  application  for  the  wound,  but 
liquor  ammonise  is  probably  better.  Brandy  and  ammonia  should 
be  given  internally  when  great  depression  exists. 

The  bite  of  the  tarantula  is  very  troublesome  and  is  often 
followed  by  nervous  depression,  vomiting  and  local  pain.  The 
bite  of  the  spider  is  very  similar  in  its  effects  to  that  of  the  scor- 
pion, though  the  wonderful  stories  as  to  its  poisonous  qualities 
are  now  regarded  as  fabulous. 

Serpent-bites  are  often  serious,  and  at  times  fatal.  Stimu- 
lants should  be  given  in  large  quantities  and  the  part  cauterized 
by  nitric  acid,  carbolic  acid,  or  nitrate  of  silver  (Bryant). 


SUDAMHSTA — SHOCK    AND    COLLAPSE.  539 

SUDAMINA. 

Is  an  eruption  which  consists  of  little  elevations  of  the  cu- 
ticle, about  the  size  of  pinheads,  tilled  with  a  watery  fluid  (miliary 
vesicles),  which  consists  of  the  secretion  from  the  sudoriparous 
glands.  It  is  usually  clear  and  transparent.  These  vesicles 
never  run  together,  are  most  abundant  on  the  neck  and  trunk, 
and  are  met  with  in  those  who  have  been  perspiring  freely  as 
the  result  generally  of  some  acute  affection,  such  as  rheumatic  or 
enteric  fever  or  pneumonia,  etc.  The  vesicles  dry  up  in  a  day 
or  to.  The  vesicles  are  due  to  the  excessive  secretion  of  sweat 
(Anderson). 

Treatment. — If  there  be  much  irritation  of  the  skin,  a  mild 
astringent  lotion  may  sometimes  give  relief.  We  should  do  our 
best  to  keep  the  patient  cool  (Anderson). 

SHOCK  AND  COLLAPSE. 

Are  terms  used  to  signify  the  loss  of  power  which  imme- 
diately follows  severe  injuries,  especially  those  attended  with 
violence.  It  is  due  to  reflex  paralysis  of  the  vaso-motor  system 
of  nerves.  The  gradations  of  shock  and  collapse  are  innumera- 
ble, and  the  symptoms  by  which  they  are  characterized  vary  from 
a  passing  faintness  or  disturbance  of  the  heart's  action  to  final 
syncope.  The  state  of  collapse  may  be  regarded  as  a  chronic 
syncope  (Bryant). 

Causes. — Shoch  may  be  caused  by  any  severe  injury,  esj^eci- 
ally  gunshot  wounds,  compound  fractures,  severe  burns,  pro- 
tracted surgical  operations  and  all  cases  in  which  serious  injury 
is  attended  with  violence,  pain  and  loss  of  blood.  Mental  shocks 
may  be  as  severe  and  fatal  as  those  of  the  body,  as  for  instance: 
A  man  receiving  unexpectedly,  some  startling  news  which 
excites  severe  emotion  and  dying  suddenly  is  said  to  die  from 
shock;  a  second  receives  a  fatal  blow  upon  the  epigastrium;  a 
third  is  struck  dead  by  lightning;  death  in  each  case  is  said  to 
be  due  to  shock.  In  all  the  heart's  action  is  suddenly  arrested 
through  the  nerve  centre — in  one  case  through  the  mind,  and  in 
the  others  through  the  body  (Bryant). 


540  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Symptoms. — A  man  receives  an  injury  and  is  not  killed,  but 
collapsed.  He  has  sustained  a  shock  more  or  less  intense  and  as 
a  consequence  becomes  cold  and  almost  pulseless.  His  skin  ap- 
pears to  be  bloodless  and  covered  with  a  cold  clammy  sweat.  He 
breathes  with  sighs  and  gasps.  His  nostrils  dilate,  his  eyes  are 
dull  and  vision  is  imperfect.  Sometimes  shock  is  so  severe  that 
the  patient  sinks  from  it  without  reaction.  It  should  be  noted 
that  vomiting  is  often  the  first  indication  of  reaction  in  general 
collapse  as  it  is  often  in  that  of  head  injuries.  Patients  with  bad 
kidneys  are  very  liable  to  suffer  from  shock  and  to  succumb  to 
any  operation,  however  trival  (Bryant). 

Treatment. — The  patient  must  be  kept  in  a  horizontal  rjosi-. 
tion;  free  access  to  air  provided;  and  cold  water  dashed  into  his 
face.  In  severe  cases  whisky  should  be  injected  under  the  skin. 
Hot  brandy  and  water,  if  the  patient  can  swallow  it,  is  probably 
more  efficient  than  anything  else.  External  warmth  should  be 
secured  by  means  of  blankets,  hot  flannels,  and  hot  water  bottles. 
Bleeding,  if  any  exist,  must  of  course  be  checked  (Bryant). 

SUPPRESSION  OF  URINE. 

In  suppression  no  fluid  comes  down  the  ureters  into  the 
bladder. 

Causes. — Suppression  may  be  caused  by  fright  or  strong 
mental  emotions,  injury  to  the  kidneys,  or  the  onset  of  an  inflam- 
matory attack,  and  by  the  effect  of  cold,  or  if  the  kidney  be  the 
seat  of  previous  chronic  disease,  by  operations  on  the  bladder  or 
urethra,  or  even  by  the  introduction  of  a  sound  or  lithotrite,  by 
the  passage  of  kiduey-stone,  etc.  (Keyes). 

Symptoms. — Are  depression,  languor,  with  apprehension, 
more  or  less  fever,  with  hot,  dry  skin,  and  hard  pulse.-  There 
may  be  chill,  vomiting,  headache,  and  pain  in  the  back  and  loins 
with  constipation.  No  urine  is  voided,  or  only  a  little  high- 
colored  secretion.  Suppression  may  come  on  gradually  from  ad- 
vancing chronic  kidney  disease.  In  this  case,  there  is. usually 
anasarca.  The  urea  and  other  products  of  waste  accumulate  in 
the  blood  and  the  patient  becomes  poisoned  by  them.  Drowsi- 
ness and  stupidity,  perhaps  delirium  and   coma,    come   on;  there 


SYNOVITIS.  541 

may  be  convulsions,  and  the  patient  dies  in  from  two  to  five  days. 
On  the  other  hand,  cases  of  suppression  after  scarlet  fever,  one  of 
seventeen  and  another  of  thirty  days,  have  been  reported.  Sup- 
pression for  seventeen  months,  with  recovery  has  been  recorded 
(Keyes). 

Diagnosis. — Is  easy.  In  retention  the  bladder  is  full,  in 
suppression  empty  (Keyes). 

Treatment. — Dry  cups  and  hot  fomentations  over  the  kidneys, 
hot-air  bath  and  hydragogue  laxatives,  the  free  use  of  warm 
drinks,  flaxseed-tea,  etc.;  and  if  there  be  no  inflammatory  condi- 
tion full  doses  of  acetate  of  potash  and  infusion  of  digitalis  may 
be  tried. 

SYNOVITIS. 

Is  an  inflammation  of  the  synovial  membrane.  It  may  be 
acute  or  chronic. 

Causes. — This  disease  may  be  caused  by  wrenches,  blows, 
punctures,  strains,  exposure  to  cold,  or  sudden  changes  of  tem- 
perature after  violent  exercise,  or  may  be  dependent  upon  con- 
stitutional affections,  such  as  rheumatism,  gout,  or  syphilitic 
or  gonorrhoeal  poisons,  etc.  Scrofula  may  cause  a  synovitis 
(Loomis  and  Sayre). 

Symptoms. — The  knee  is  the  joint  most  frequently  affected. 
There  is  severe  aching  pain  in  the  joint,  increased  by  motion, 
great  swelling,  redness  of  the  surface,  tenderness  and  fever.  As 
a  rule,  synovitis  does  not  affect  more  thau  one  joint;  and  as  there 
is  scarcely  any  or  no  effusion  into  the  surrounding  tissue,  the  out- 
line of  the  joint  can  be  distinctly  discerned  and  fluctuation  is 
readily  detected.  When  the  knee  is  affected  the  patella  is 
pushed  forward  and  there  is  great  fullness  on  each  side  of  it  and 
at  the  lower  and  front  part  of  the  thigh  (Sayre  and  DaCosta). 

Treatment. — The  limb  must  be  kept  absolutely  motionless. 
A  splint  must  be  applied  so  as  not  to  touch  the  affected  part. 
Leeches  to  the  joint,  cups  in  the  neighborhood  and  evaporating 
lotions  or  hot  fomentations  are  useful.  Calomel  purgatives 
should  be  administered  and  opiates  to  relieve  pain.  When  there 
is  a  tendency  of  the  disease  becoming  chronic  iodide  of  potassium 
.should  be  administered.     And  if  the  disease   be  connected  with 


542  A    COMPENDIUM    OE    PRACTICAL     MEDICINE. 

rheumatism  ammonia  and  potash  should  be  prescribed.  Where 
there  is  a  tendency  to  gout,  colchicum  with  potash  is  to  be  em- 
ployed. In  syphilitic  cases,  mercury  in  its  different  forms  is 
most  to  be  relied  upon  (Horwitz). 

SYPHILIS. 

Is  a  general  dyscrasial  blood- disease  caused  by  the  absorp- 
tion of  a  peculiar  virus  into  the  circulation,  manifesting  itself 
primarily  by  the  appearance  of  a  poisonous  sore  at  the  point 
where  the  virus  entered,  and  afterwards  by  a  succession  of 
morbid  manifestations  occurring  at  longer  or  shorter  intervals, 
which  may  affect  every  organ  and  tissue  of  the  body.  The  virus 
is  only  known  by  its  effects.  Exactly  what  it  is  has  not  yet  been 
determined.  But  it  is  more  than  probable  that  it  is  a  living 
contagious  element. 

Diday  and  Rollet  failed  to  inoculate  syphilis  upon  cancerous 
patients,  and  assume  an  antagonism  between  the  two  maladies; 
but  Keyes  says,  "This  surely  does  not  exist,  as  I  have  seen  many 
of  the  varieties  of  cancer  upon  syphilitic  patients." 

Hutchinson  has  happily  compared  syphilis  to  the  contagious 
exanthemata,  small-pox,  measles,  scarlet  fever,  as  possessing  all 
the  peculiar  characters  common  to  this  group  of  diseases,  namely: 
it  is  communicated  only  from  one  diseased  person  to  another 
healthy  one;  it  has  a  stage  of  incubation  before  any  sign  of  the 
disease  appears;  it  has  a  stage  of  efflorescence,  which  indeed  in 
syphilis  is  prolonged  and  marked  by  relapses;  it  has  a  period  of 
decline  and  sequelae — the  later  tertiary  lesions — which  do  not 
always  occur,  and  during  which  the  disease  often  ceases  to  be 
communicable. 

Again,  most  of  the  varied  efflorescences  of  syphilis,  like 
those  of  the  other  exanthemata,  tend  to  pass  away  spontaneously 
after  a  time;  thus,  as  Fournier  aptly  puts  it,  affording  a  triumph 
to  every  method  of  treatment.  One  attack  confers  immunity 
from  another  often  for  life,  alwaj^s  for  a  long  period.  The  dis- 
ease is  transmissible  by  inheritance,  as  in  the  case  of  the  other 
exanthemata  when  the  child  is  born  before  the  mother  recovers 
from  disease.     Finally  the  sequelae  do  not  constitute  transmissi- 


SYPHILIS.  543 

ble  disease  even  by  inheritance.  As  in  the  other  zymotic  dis- 
eases, a  portion  of  the  virus,  however  small,  is  capable  of  infect- 
ing the  whole  body  as  if  by  fermentation.  Thus  the  analogy  of 
syphilis  with  the  contagious  exanthemata  is  clear,  only  its  febrile 
symptoms  are  less  marked,  its  efflorescences  more  varied,  and  its 
course  much  more  protracted — counted  by  months  instead  of 
days — and  more  subject  to  variation  as  well  as  more  amenable  to 
treatment.  Syphilis  is  fortunately  only  contagious,  it  is  not  in- 
fectious; its  poison  is  not  volatile,  is  not  diffused  in  the  air; 
direct  contact  of  the  virus  with  a  surface  capable  of  absorption 
is  essential  to  the  production  of  the  disease. 

A  patient  may  have  malignant  scarlet  fever  and  die  in  a 
day  without  a  sign  of  eruption,  but  still  he  has  scarlet  fever,  as 
no  one  denies.  Even  if  one  syphilitic  chancre  out  of  twenty 
were  not  indurated  the  other  nineteen  would  be  amply  sufficient 
to  establish  a  rule.  But  the  proportion  is  far  larger  and  there  is 
perhaps  no  symptom  of  any  disease  more  constant  than  is  the  in- 
duration of  syphilitic  chancre,  yet  the  patient  does  not  have  syph- 
ilis because  his  chancre  indurates,  he  already  has  syphilis 
before  his  chancre  appears.  If  he  did  not  have  it  he  could 
have  no  chancre  at  all  and  the  induration  of  that  chancre  is 
just  as  much  one  of  its  symptoms  as  is  ulceration  of  a  chancroid. 
A  patient  who  has  absorbed  syphilitic  virus  has  syphilis  at  once, 
and  because  he  has  syphilis  he  gets  a  sore  at  the  point  of  en- 
trance of  the  poison  after  a  period  of  incubation,  as  the  first 
symptom  of  the  disease.  This  chancre  may  be  destroyed  by 
caustic,  or  the  knife,  but  the  disease  will  run  its  course  unaltered 
(Keyes). 

Interval  Before  Absorption. — Clerc  tells  of  a  medical  student 
who  washed  himself  immediately  after  sexual  intercourse  and  on 
careful  examination  for  several  days  subsequently  detected  abso- 
lutely nothing;  twenty- eight  days  afterward  chancre  appeared, 
followed  by  general  syphilis.  Hill  relates  the  case  of  a  man  who 
in  sexual  intercourse  tore  his  frsenum  which  bled  freely  and  fear- 
ing infection  called  upon  Hill  within  twelve  hours  after  the  acci- 
dent to  cauterize  it  with  fuming  nitric  acid.  About  one  month 
afterward  the  scar  indurated.     It  never  ulcerated  again   but  the 


544  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

regular  manifestations  of  true  syphilis  came  on  at  the  usual  in- 
tervals. 

Diday  cauterized  a  syphilitic  chancre  within  six  hours  after 
its  appearance;  but  although  the  sore  healed  promptly,  general 
syphilis  followed.  The  rapidity  of  absorption  of  the  poison  of  a 
snake-bite  is  well-known,  as  is  also  that  of  rabies  and  the  poison 
of  a  dissecting  wound,  and  there  is  no  reason  why  that  of  syph- 
ilis should  be  less  so  (Keyes). 

Second  Attack  of  True   Syphilis. — Hutchinson   saw   a   well- 
marked  case,  in  a  physician,  of  two  attacks  of  syphilis,  each  pre- 
ceded  by  its  characteristic  syphilitic  chancre.     The  same  patient 
had  had  small-pox  twice.     He  records  a  case  in  which  a  woman 
with  mild  inherited  syphilis  got  a  new  attack  in  the  usual  way 
at  the  age  of  twenty.     Diday  has  collected  twenty-five  cases,  of 
which  he  personally  saw  twenty,  of  reinfection.     In  all  of  these 
cases  there  was  syphilitic  chancre  with  characteristic  induration, 
occurring  a  second  time  after  a  previous  syphilis.     Diday  con- 
cludes that  the  minimum  time  for  the  cure  of  syphilis  is  twenty- 
two  months,  and  that,  where  syphilitic  chancre  appears  twice  in 
the  lifetime  of  an  individual,  the  second  attack  should  not  be 
treated  until  syinjjtonis  of  secondary  syphilis  appear,  as  these 
may  never  come  on,  the  whole  attack  consisting  simply  in  syph- 
ilitic chancre.     Keyes  says  that  he  can  honestly  state  that  he  has 
never  seen  a  case  of  syphilitic  reinfection  to  recognize  it.     He 
also  says,  "While,  then,  a  second  true  syphilitic  infection  is  pos- 
sible even  while  the  subject  bears  the  marks  of  late  tertiary  dis- 
ease, yet  such  infection  is  eminently  exceptional,  and  allowance 
must  be  made  in  the  reported  cases  for  (1)  chancroid  accom- 
panied by  some  eruption,   as  a  coincidence;   (2)   ecthyma  mis- 
taken for  syphilis,  after  which  the  first  true  syphilitic  infection 
might  pass  for  a  second;   (3)  false  chancre,  indurated  mucous 
patch;  and  (4)  cases  of  tertiary  ulcer  faultily  diagnostic•ated,, 
(Keyes). 

Transmissibility  to  Animals. — Besides  this  peculiarity  of  only 
appearing  once  in  a  given  individual,  syphilis  differs  from  chanc- 
roid in  not  being  transmissible  to  animals.  So  far  as  experimen- 
tal demonstration  yet  goes,  it  must  be  asserted  thatthesad  privi- 
lege of  having  true  syphilis  belongs  only  to  man  (Keyes). 


SYPHILIS.  545 

Incubation  of  Syphilis. — After  the  poison  of  syphilis  has  been 
absorbed,  the  break  in  the  epithelium  through  which  it  entered 
heals,  and  the  virus  ferments  as  it  were,  in  the  blood,  until  it  is 
ready  to  give  itself  local  expression,  first  at  the  point  of  entrance 
in  the  form  of  syphilitic  chancre.  This  period  of  incubation  or 
hatching,  has  been  critically  studied  by  many  authors,  both  by 
inoculation  upon  healthy  subjects  and  clincially  by  close  observa- 
tion of  patients.  The  usual  period  after  contact,  or  inoculation, 
at  which  a  chancre  first  appears  is  about  the  end  of  the  third 
week.  In  exceptional  cases  it  may  be  ten  weeks.  The  longest 
period  of  incubation  that  Keyes  could  find  among  the  authentic 
cases  of  experimental  inoculation  is  forty-six  days.  There  is  no 
case  on  record  of  an  incubation  less  than  nine  days,  except  one 
case  reported  by  Taylor,  and  one  by  Hammond.  During  the 
period  of  incubation  the  patient  bears  no  sign  of  disease.  Dur- 
ing the  fourth  week  after  exposure  a  syphilitic  chancre  appears, 
and  this  is,  perhaps,  the  most  valuable  mark  of  a  syphilitic 
chancre,  and  practically  all  sores  appearing  later  than  ten  days 
after  suspicious  contact  must  be  regarded  with  distrust,  while 
those  coming  sooner  may  be  more  lightly  considered  (Keyes). 

Multiple  Inoculation. — It  has  been  found,  that  where  many 
points  were  inoculated  at  the  same  time,  usually  all  took  and 
appeared  simultaneously  as  chancres.  Inoculations  made  upon 
different  individuals,  with  virus  derived  from  the  same  lesion,- 
have  required  different  periods  of  incubation  for  their  develop- 
ment. Hunter  said,  that  syphilis  was  not  reinoculable  upon  an 
already  infected  person.  Fournier  believes  that  about  two  per 
cent,  of  auto-inoculations  of  syphilitic  chancre  take.  The  rule 
then  is  this :  Reinoculations  of  syphilitic  virus  upon  patients 
already  syphilitic  produce  no  results.  Auto-  or  hetero-inocula- 
tion  upon  a  patient  with  very  young  chancre  is  occasionally  suc- 
cessful. Hetero- inoculation  during  the  late  tertiary  stage  of  the 
disease  is  more  often  successful.  At  both  of  these  periods  the 
patient  is  not  fully  protected,  the  system  not  being  saturated 
with  the  syphilitic  poison  at  first,  and  the  virus  beiiuj;  at  a 
minimum  toward  the  end  (Keyes). 

Secretions  Capable  of  Transmitting  Syphilis  l"j  Inocula- 
tion.— Inoculations  of  healthy  subjects  with  the  fluid  secreted  by 


546  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

syphilitic  chancre,  mucous  patches,  any  secondary  cutaneous  or 
mucous  lesion  yielding  a  discharge,  and  of  syphilitic  blood 
drawn  from  a  patient  with  an  eruption,  taken  either  from  a 
papule,  or  tubercle,  or  from  the  healthy  skin  between  the  lesions 
— all  such  inoculations  yield  indurated  chancre  after  a  period  of 
incubation,  which  chancre  is  succeeded  by  general  syphilis.  The 
blood  of  syphilis  is  poisonous  in  the  intermediary  periods  be- 
tween the  eruptions,  when  the  skin  and  mucous  membranes  are 
sound,  as  vaccinal  syphilis  proves. 

The  secretions  of  other  pathological  lesions  not  syphilitic  will 
not  produce  syphilis  unless  some  of  the  patient's  blood  be  inocu- 
lated at  the  same  time.  Gonorrhoea  acquired  from  a  syphilitic 
patient  having  at  the  time  only  gonorrhoea,  repioduces  itself  as 
gonorrhoea  and  not  as  syphilis.  The  same  is  true  of  chancroid. 
Diday  inoculated  pus  from  a  pustule  of  acne  produced  upon  a 
patient  "in  full  syphilis  "  by  the  administration  of  iodide  of 
potassium.  The  result  was  negative.  The  same  is  true  of  the 
vaccine  virus.  Pure  vaccine  virus  taken  from  a  syphilitic  pa- 
tient before  there  is  any  pus  in  the  vesicle  will  produce  vaccinia 
only,  if  no  blood  be  inoculated.  Since  syphilis  can  been  commun- 
cated  by  vaccination  it  is  wiser  always  to  use  lymph  from  the 
calf  and  never  humanized  virus.  Inoculation  has  failed  to  pro- 
duce positive  results  from  ulcers  of  the  late  tertiary  period  of 
syphilis.  Diday  inoculated  sixteen  times  with  blood  from  pa- 
tients suffering  from  tertiary  syphilis  (nodes),  always  with  neg- 
ative results.  The  fact  that  patients  with  tertiary  syphilis  may 
occasionally  acquire  a  chancre  and  the  earlier  eruptions  anew 
and.  the  other  undoubted  fact  that  such  patients  may  procreate 
healthy  offspring,  render  it  still  more  certain  that  late  tertiary 
syphilis  is  no  longer  either  communicable  or  transmissible.  But  on 
the  other  hand,  women  who  have  positive  tertiary  symptoms  un- 
doubtedly procrerate  diseased  children  sometimes,  just  as  they  as 
certainly  often  produce  healthy  ones.  Hence  tertiary  syphilis 
may  be  said  to  be  generally  but  not  always  free  from  the  dan- 
gers of  transmission  and  communicability.  The  older  the  disease 
the  less  apt  it  is  to  be  transmitted.  The  male  loses  the  power  of 
transmission  seemingly  long  before  the  female. 


SYPHILIS.  547 

None  of  the  physiological  secretions  or  excretions  can  pro- 
duce syphilis  by  inoculation.  Mucus  from  the  mouth  of  a  syph- 
ilitic patient  having  no  lesions  of  the  mucous  membrane  at  the 
time  has  been  tested  often.  Diday  has  inoculated  saliva  without 
success.  If  mucous  patches  exist,  then  the  saliva  produces  chan- 
cre when  inoculated,  as  shown  by  the  interesting  cases  of  tattoo- 
ing reported  by  Maury.  Vidal  has  proved  the  harmlessness  of 
tears,  and  the  sweat  and  urine  have  been  in  a  similar  way  re- 
lieved of  blame.  The  semen  has  been  inoculated  by  Mireur, 
taken  from  a  man  in  the  full  bloom  of  secondary  eruptive  disease. 
Milk  from  a  syphilitic  woman  is  neither  inoculable  experiment- 
ally nor  does  it  give  the  disease  to  the  child  who  drinks  it. 
Where  the  nurse  has  a  syphilitic  lesion  of  the  nipple,  the  child 
surely  becomes  j)oisoned  if  it  have  a  fissure  or  other  abrasion  of 
the  lips  through  which  the  poison  can  be  absorbed;  but  in  such 
case  syphilis  in  the  child  is  always  preceded  by  chancre  of  the 
lips  or  mouth  (Keyes). 

Methods  of  Transmission  of  Syphilis. — Syphilis  always  com- 
mences as  a  chancre,  with  two  exceptions — or  rather  one  alleged 
exception,  the  choc-en-retour /  the  other  a  real  exception — that 
of  inherited  disease. 

Choc-en-retour. — Keyes  says,  "This  is  a  misty  condition, 
probably  only  a  high-sounding  title  to  conceal  ignorance."  In  it 
the  ovule  of  a  healthy  woman  is  supposed  to  be  infected  with 
syphilis  by  the  semen  of  the  syphilitic  father,  a  semen  which  the 
direct  test  of  inoculation  proves  to  be  void  of  any  poison.  The 
syphilitic  germ  grows,  and  in  its  turn  poisons  the  mother,  who 
thus  becomes  diseased  without  the  necessity  of  having  any  pri- 
mary lesion.  Because  no  chancre  has  been  observed  in  these 
cases  dose  not  prove  that  she  never  had  it.  Many  a  woman,  tjos- 
sibly  the  greater  number  having  syphilis,  gets  the  disease  without 
any  knowledge  of  the  primary  lesion. 

The  Choc-en-retour  does  not  appear  very  reasonable,  because 
it  has  not  been  proved  absolutely  that  the  s}rphilitic  father,  the 
mother  remaining  sound,  can  infect  the  child  through  the  semen 
(  Keyes ). 

Inherited  Syphilis. — When  a  child  is  born  with  inherited 
syphilis,  it  naturally  never  has  had  a  chancre — a  primary  lesion.  N<  > 


548  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

one  doubts  that  a  mother  in  active  syphilis  aborts,  miscarries,  or 
produces  a  diseased  child.  As  to  whether  the  father  can  pro- 
duce a  diseased  child  by  infecting  the  ovum  through  impregna- 
tion without  infecting  the  mother  (and  through  her  the  ovum), 
is  a  question  not  yet  settled.  That  a  father  may  have  syphilis 
and  still  have  a  healthy  child  is  proved  by  Mireur.  He  leans  to- 
ward the  belief  that,  if  the  mother  escape,  a  syphilitic  father  can 
not  produce  a  syphilitic  child.  He  also  demonstrates  that  both 
parents  may  still  suffer  from  tertiary  lesions,  and  produce  seem- 
ingly healthy  children.  When  the  mother  has  syphilis,  it  has 
been  shown  that  she  may  have  a  healthy  child  while  under 
treatment,  and  a  diseased  one  if  the  treatment  be  left  off  before 
she  has  passed  the  virulent  stage  of  the  disease. 

Finally,  that  a  man  himself  syphilitic,  with  a  syphilitic  wife 
and  a  non- syphilitic  mistress,  may  have  a  diseased  child  by  the 
former  and  a  healthy  child  by  the  latter,  the  two  children  being 
born  within  fifteen  days  of  each  other,  seems  to  be  fully  proved 
by  Charrier's  case.  Keyes  says,  "The  great  stumbling-blocks  to 
me,  standing  in  the  way  of  my  seriously  accepting  the  fact  that 
a  child  may  be  born  syphilitic  and  still  have  a  healthy  mother, 
are  the  failure  of  direct  inoculation  upon  such  mothers,  and  the 
so-called  Colles's  law,  namely,  a  child  born  syphilitic  can  not 
poison  its  own  mother,  but  may  poison  a  healthy  wet-nurse'1 
(Keyes). 

The  Methods  of  Contagion  are  Immediate  and  Mediate. — 
Syphilis  is  very  often  transmitted  by  means  other  than  sexual 
contact,  more  so  than  chancroid.  Surgeons  and  accoucheurs  get 
chancre  of  the  fingers  by  inoculating  abraded  spots  in  the  exer- 
cise of  their  professional  duties,  and  in  their  turn  may  spread  the 
disease.  A  midwife,  with  a  syphilitic  lesion  upon  her  finger  of 
which  she  was  aware,  communicated  the  disease  directly  and 
indirectly  to  forty- five  persons.  She  was  convicted  and  sen- 
tenced to  twelve  months'  hard  labor.  Chancre  is  frequently 
transmitted  in  kissing,  a  little  mucous  patch  in  the  mouth  of  one 
party  poisoning  any  fissure  on  the  lips  of  the  other.  Both  of 
these  methods  are  immediate. 

Children  acquire  chancre  of  the  lips  from  nursing-women 
with  mucous  patches   of  the   nipple,   and,   on   the   other  hand, 


syphilis.  549 

health)7  nurses  get  chancre  of  the  nipple  By  suckling  children 
with  inherited  syphilis  who  have  mucous  patches  of  the  lips. 
Colles's  law  that  a  child  with  mucous  patches  of  the  month  can 
not  produce  ulceration  of  the  nipple  if  it  sucks  its  mother, 
depends  simply  upon  the  fact  that  its  mother  already  has  syph- 
ilis before  the  child  is  born,  and  consequently  can  not  get  a  new 
chancre  of  the  nipple.  The  following  are  examples  of  mediate 
contagion:  Puche  speaks  of  a  gentleman  with  a  long  prepuce, 
who,  after  marriage,  encountered  an  old  mistress,  with  whom  he 
had  intercourse.  Returning  home  shortly,  without  having 
washed,  he  repeated  sexual  intercourse  with  his  wife,  depositing 
the  virus  from  his  prepuce  in  her  vagina.  He  escaped,  but  in 
due  course,  she  developed  chancre  and  general  syphilis.  A  simi- 
lar authentic  instance  is  related  of  a  woman  who  proved  unfaith- 
ful. Her  husband,  embracing  her  shortly  afterward,  relieved 
her  of  the  poison  left  in  her  vagina  by  her  lover,  himself  devel- 
oped chancre,  while  she  escaped. 

Smokers  of  a  pipe  sometimes  get  chancre  of  the  lip>s,  the 
virus  being  deposited  upon  the  mouth -piece  of  the  pipe  by  some 
previous  smoker  who  had  mucous  patches  of  the  lip.  Toys  may 
communicate  the  disease  to  a  child;  tooth-brushes  and  cigars  to 
an  adult.  Glass-blowers  get  syphilis  in  the  same  manner,  as 
they  work  in  sets  of  three  at  the  same  tube,  passing  it  from 
mouth  to  mouth.  Syphilis  sometimes  runs  through  a  whole 
family,  from  the  use  of  the  same  spoons  or  cups,  passed  from  one 
mouth  to  another.  Washerwomen  become  infected  in  cracks  of 
the  fingers  through  the  virus  contained  upon  soiled  clothes. 
Wet- cups,  transplanting  teeth  and  passing  the  Eustachian  cathe- 
ter have  proved  sources  of  mediate  contagion.  Circumcision 
and  vaccination  are  familiar  instances  of  mediate  contagion.  In 
all  such  cases  chancre  precedes  the  development  of  general 
syphilis  (Keyes). 

For  the  Induration,  Ulceration  and  (rear nil  Characters  of 
a  Chancre,  see  Chancre. 

For  Syphilitic  Bubo,  see  Bubo. 


550  A    COMPENDIUM    OF    PRACTICAL     MEDICINE 

GENERAL  SYPHILIS. 

Primary  syphilis  includes  the  chancre  and  its  accompany- 
ing adenitis,  and  lymphangitis.  A  chancre  never  does  nor  can 
appear  elsewhere  than  at  that  point  through  which  the  poison 
first  entered  the  body.  Hence,  inherited  syphilis  has  no  primary 
stage,  but  is  general  from  the  start. 

Primary  Syphilis,  so  far  as  its  manifestations  go,  is  purely 
local.  Not  so  with  general  syphilis.  There  is  no  organ  or  tissue 
of  the  body  through  which  it  may  not  manifest  its  presence  by 
symptoms.  The  lymphatic  glands  all  over  the  body  may  suffer. 
The  skin  from  crown  to  sole,  the  nails,  the  hair,  and  the  mucous 
membranes  have  their  peculiar  affections  due  to  syphilis.  The 
eye  and  the  testicle  do  not  escape,  and  each  and  every  viscus  is 
liable  to  be  invaded,  as  are  all  the  tissues,  connective  fibrous, 
muscular,  cartilage,  bone,  brain,  nerve,  and  vessel.  The  all-em- 
bracing arms  of  general  syphilis  may  destroy  any  function. 
Syphilis  may  destroy  any  special  sense,  produce  local  or 
general  paralysis,  acute  or  chronic  mania,  dementia,  lunacy, 
idiocy,  etc. 

General  Syphilis  has  been  divided  into  a  secondary  and 
tertiary  stage. 

Secondary  Syphilis  includes  all  the  earlier  affections  of  the 
skin  and  mucous  membranes,  and  many  of  the  lighter  affections 
of  the  eye,  testicle,  and  other  glands,  with  some  of  the  varieties 
of  nervous  syphilis. 

Tertiary  Syphilis  follows  secondary,  and  consists  of  the 
later  and  the  ulcerative  skin- affections,  the  deeper  lesions  of  con- 
nective tissues,  muscle,  bone,  cartilage,  and  of  the  internal  or- 
gans and  all  gummy  deposit. 

Secondary  syphilis  lasts  often  a  year,  sometimes  two  or 
more. 

Tertiary  syphilis  (except  as  malignant)  does  not  commence 
till  after  the  expiration  of  at  least  one  year  from  the  appearance 
of  the  chancre.  It  may  never  show  itself,  or  may  appear  after  a 
period  of  health  of  many  years,  often  five  or  ten,  sometimes  as 
late  as  fifty- two  (Fournier).  The  whole  secondary  stage  may 
be  skipped  under  treatment,  or  even  without  treatment  (Keyes). 


SYPHILIS.  551 

Syphilicles. — The  most  conspicuous  symptoms  of  general 
syphilis  affect  the  skin,  and  are  known  as  syphilicles  or  syphilo- 
dermata.  It  may  be  papular,  vesicular,  or  pustular  syphilide 
(Keyes). 

Prognosis. — Babies  with  inherited  syphilis  suffer  more  than 
any  other  class.  The  malady  is  often  fatal  with  infants.  Next 
in  severity  come  the  cases  acquired  in  early  manhood.  Excesses 
of  every  sort,  of  wine,  of  women,  of  work,  are  liable  to  intensify 
the  type  and  duration.  All  local  irritations  tend  to  call  out 
eruptions  at  the  points  irritated.  A  child  born  with  inherited 
syphilis  may  give  no  evidence  of  his  malady  until  he  is  vaccin- 
ated, when  an  eruption  may  appear.  A  blister  may  call  out 
dormant  syphilis  upon  an  adult.  Patients  who  work  much  with 
the  hands  are  more  liable  than  others  to  eruptions  of  the  palms. 
Tobacco  chewed  or  smoked  is  proverbial  for  its  power  of  origin- 
ating and  maintaining  mucous  patches  in  the  mouth.  The  rough 
edge  of  a  tooth  may  keep  up  a  mucous  patch  of  the  tongue. 
When  a  bone  breaks  in  a  syphilitic  subject,  even  in  one  with 
latent  syphilis,  it  may  fail  to  unite  unless  iodide  of  potassium  be 
given.  The  prognosis  is  more  unfavorable  with  bad  hygiene 
(Keyes). 

Duration  of  General  Syphilis. — There  is  no  disease  so  protean 
in  its  form  as  syphilis.  Its  symptoms  simulate  those  of  a  vast 
number  of  other  diseases.  So  true  is  this  that  it  has  passed  into 
a  proverb  in  the  face  of  an  obscure  disease,  "If  you  do  not  know 
what  to  do,  treat  the  patient  for  syphilis.*"  It  is  difficult  to  say 
wxhen  syphilis  has  ended  or  of  deciding  that  it  ever  does  end. 
Syphilis  may  occur  in  so  mild  a  form  that  the  patient  may  never 
know  he  has  it.  Syphilis  may  manifest  itself  as  a  mild  eruption 
after  chancre,  disappearing  possibly  without  treatment,  and  then 
lie  latent  for  many  years,  as  long  as  fifty -two  years,  to  reappear. 
Keyes  has  a  case  where  syphilis  was  latent  for  about  forty  years. 
Syphilis  once  acquired,  stamps  its  impress  upon  the  individuality 
of  the  patient  and  becomes  a  part  of  him  and  no  power  on  earth 
in  a  given  case  can  say  when  that  impress  disappears.  A  half 
century  may  pass  away  and  the  trail  of  the  serpent  be  still  visi- 
ble. Yet  syphilis  may  be  cured.  The  virulence  of  syphilis  dis- 
appears in  the  late  tertiary  period  and  during  this  period  neither 


552  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  blood  nor  the  pathological  secretions  will  infect  a  healthy 
subject  with  the  disease.  Of  the  two  diseases  gonorrhoea  and 
syphilis,  the  former  sends  more  patients  to  the  tomb  than  the 
latter.  Keyes  says  that  a  man  may  get  chancre,  followed  by 
some  light  eruption,  consider  it  of  no  importance  and  get  well 
spontaneously,  marry  and  have  healthy  children,  himself  remain- 
ing entirely  free  from  any  evidence  of  the  disease  and  dying  in  a 
green  old  age  (Keyes). 

Syphilis  and  Marriage. — If  a  patient  presents  himself  with 
syphilitic  chancre,  at  what  period  may  he  safely  marry  ?  He 
should  not  marry  earlier  than  four  years  after  chancre,  and  it  is 
better  not  to  marry  for  five  years  (Keyes). 

Causes  of  tlie  Protracted  Duration  of  SyphiUs. — 1.  Those 
living  in  bad  hygienic  surroundings,  and  giving  themselves  up 
to  excesses  of  every  sort.  2.  Patients  peculiarly  susceptible  to 
the  disease.  3.  Patients  possessed  of  a  strong  tendency  to  gout 
or  scrofula.     4.  Those  who  treat  irregularly. 

General  Characteristics   of  Syphilides. — 1.  Polymorphism 
of  the  earlier  eruptions.     2.  Rounded  form    of   the    patches    of 
eruption,  and  of  the  ulcers.     3.  Livid  color,  like  the  meat  of  raw 
ham,  then  coppery  (pigmented),  then  gray,  then  white.     4.  Ab- 
sence of  pain  and  itching.     5.  The  earlier  eruptions   are    distri 
buted  habitually  all  over  the  body,  are  superficial,    mainly    con 
gestive,  and  usually  symmetrical.     6.  Later  eruptions  in  groups 
involving  the  cutis  vera.     7.  Scales  white,  usuallyjnot  adherent 
superficial.     8.  Crusts   or  scabs  greenish,  black,  irregular,  thick 
adherent.     9.  Ulcers  with  abrupt  edges,    adherent,    not    under 
mined,  sluggish,  and  bleeding  easily.     10.  Cicatrix  rounded,  de 
pressed,    thin,  non-adherent,  white,  smooth  at  first,  shining,  often 
pigmented,  then  clearing  off  from  the  centre  toward  the  circum- 
ference (Keyes). 

Secondary  Incubation. — Primely  incubation  extends  from  the 
moment  of  suspicious  contact  to  the  a23pearance  of  the  chancre. 
This  period  is  about  three  weeks.  .  Then  primary  syjDhilis  is 
ushered  in;  but  now  there  is  another  period  of  rest,Jwherein  the 
disease  seems  to  be  purely  local.  This  period  dates  from  the 
appearance  of  the  chancre  to  the  appearance  of  general  symp- 
toms, and  is  called  secondary  incubation.     This  period  is  on  an 


SYPHILIS.  553 

average  six  weeks,  but  may  be  shorter  or  longer.  In  rare  cases 
the  entire  secondary  period  may  be  skipped,  the  disease  first 
appearing  in  its  tertiary  form.  This  is  termed  delayed  syphilis 
(Keyes). 

Syphilitic  Fever. — About  a  week  or  more  before  the  appear- 
ance of  any  eruption,  the  jjatient  is  liable  to  have  fever.  The 
poison  of  syphilis  reduces  the  number  of  red  blood  corpuscles, 
and  produces  more  or  less  cachexia.  This  syphilitic  hydremia  is 
constant,  but  may  be  slight.  Fever  is  present  in  about  two- 
thirds  of  all  cases,  and  may  be  continuous,  or  it  may  occur 
only  toward  night,  followed  by  sweating.  With  the  fever  there 
may  be  a  sallow  complexion,  sunken  eyes,  melancholy,  fatigue, 
shortness  of  breath,  palpitation,  and  pain  in  various  parts  of  the 
body.  Among  the  pains  of  early  syphilis,  headache  is  promi- 
nent, and  is  usually  worse  at  night. 

The  treatment  is  mainly  tonic  doses  of  mercury  and  hygienic 
(Keyes). 

Alopecia. — Falling  of  the  hair  due  to  syphilis  is  of  two 
kinds.  Scabby  sores  on  the  scalp  cause  the  hair-follicles  to  be 
destroyed,  in  which  case  the  fallen  hair  is  not  reproduced.  Or- 
dinarily there  is  a  thinning  of  the  hair  generally,  not  only  of  the 
scalp,  but  of  the  eyebrows,  eyelids,  whiskers,  and  to  a  degree  of 
the  whole  body.  In  acquired  syphilis  the  thinning  of  the  hair  is 
due  to  one  of  two  causes  (that  is,  when  there  are  no  scabs): 
1.  The  syphilitic  hydrsemia  which,  like  fever,  impairs  the  vitality 
of  the  hair-papilke.  2.  Seborrhcea,  the  sebaceous  matter  clog- 
ging the  hair -follicle. 

Treatment. — Shampooing  once  a  week  with  ammonia  or 
borax  in  warm  water  (5j.  to  the  Oj.)  is  useful,  and  rubbing  the 
scalp  nightly  with  a  stimulating  lotion,  as  follows: 

J&     Tinct.  capsici 3ij--v. 

Gly  cerini 3j . 

Aquse  cologniensis ad oj.—  M.  — Keyes. 

Indolent  Glandular  Engorgement. — Is  a  diagnostic  mark  of 
the  first  importance  in  all  doubtful  cases  of  syphilis.  The  en- 
gorgement of  the  glands  is  indolent,  painless.  They  are  hard 
and  vary  in  size  from  a  small  pea  t<>  a  marble.  The  coincident 
indolent  engorgement  of  certain  glands  is  almost  pathognomonic 


554  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

of  syphilis.  These  are  the  post- cervical,  and  epitrochlear  glands 
on  either  side,  just  above  and  without  the  inner  condyle  of  the 
humerus  (Keyes). 

Sore  Throat. — Is  a  concomitant  symptom  of  all  stages  of 
general  syphilis.  There  are  three  type  varieties:  1.  A  diffuse 
general  redness,  with  or  without  ulceration  in  the  early  second- 
ary stage.  2.  A  certain  amount  of  chronic  congestion,  and 
brawny  thickening  about  mucous  patches  or  atonic  ulcers  in  the 
late  secondary  and  early  tertiary.  3.  Destructive  ulceration 
from  gummy  deposit  in  the  tertiary  stage  (Keyes). 

General  Treatment  of  Syphilis. — Is  hygienic,  tonic  and  specific. 

Hygienic  Treatment. — Includes  all  the  ordinary  laws  of 
health.  Eegularity  in  eating  and  sleeping  is  all -important. 
Excesses  of  any  kind  are  bad.  Warm  baths  should  be  taken 
frequently.  Catching  cold  and  the  use  of  tobacco  are  apt  to 
induce  and  prolong  mucous  patches  in  mouth  and  throat. 
Change  of  air  may  be  necessary  to  effect  a  cure.  Mercury  and 
the  iodides  will  not  cure  all  syphilis,  as  many  practitioners  seem 
to  believe. 

Tonic  Treatment. — Cod-liver  oil,  iron,  quinine  and  other 
tonics  must  be  given,  along  with  the  specific  remedies. 

Specific  Treatment. — Most  of  the  syphilides,  especially  the 
earlier  varieties,  are  self-limiting,  and  will  get  well  under  any 
treatment — one  might  even  say  in  spite  of  treatment.  No  treat- 
ment may  be  better  than  over-treatment.  Sarsaparilla  has  no 
curative  power,  but  assists  digestion  and  promotes  the  action  of 
the  skin,  and  pleases  the  patient. 

The  following  formula  is  serviceable  : 

|fc     Hydrarg.  chlorid.  corros .gr.  j. 

Aluminis 3ss. 

Ext.  sarsaparilla §ij . 

Gly  cerini oj . 

Syr.  sennas §iss. 

S pts.   anisi 3 j  • 

Ext.  glycyrrhizas 5}  ■ 

Aquas  forniculi — q.  s.,  ad sviij. — M. 

Sig. :     A  tablespoonful  several  times  daily.  — Keyes. 

Keyes  says  that  the  succus  alteram   has   very  little,  if  any, 

value  in  the  treatment    of  syphilis,  and  that    the    quackish  and 


SYPHILIS.  555 

pretentious  manner  in  which  it  is  being  forced  upon  the  profes- 
sion is  enough  to  conclem  it,  and  to  make  any  honest  man  doubt 
its  claims. 

The  Hot  Springs  of  Arkansas. — Keyes  says  the  springs  have 
a  positive  value  in  the  treatment  of  syphilis.  Patients  broken 
down,  cachectic,  with  faulty  stomachs,  who  have  syphilitic  lesions 
which  fail  to  yield  at  home  because  they  can  not  tolerate  a  suffi- 
ciently high  degree  of  medication — these  are  the  patients  to  send 
to  the  hot  springs.  This  is  the  only  class  of  patients  Keyes  ever 
sends  to  the  springs.  The  physicians  who  do  well  at  the  springs 
use  most  unsparingly  mercury  by  inunction  and  iodide  of  potas- 
sium internally  in  enormous  doses.  The  hot  water  internally 
and  the  baths  enable  a  patient  to  tolerate  large  doses.  For  ordi- 
nary syphilis  Keyes  does  not  consider  the  springs  of  any  value. 
They  do  not  shorten  the  duration  of  the  disease,  prevent  relapse, 
or  cure  it  in  any  sense.  The  rule  should  be:  Send  no  patients  to 
the  springs  who  do  well  under  ordinary  medication  at  home. 

Treatment  of  Early  Syphilis. — Should  be  commenced  as  soon 
as  the  diagnosis  of  syphilis  is  positive.  The  rule  in  all  cases  of 
doubt  is:  Do  nothing,  but  frankly  tell  the  patient  that  he  must 
wait;  or  if  he  has  not  the  grace  to  appreciate  pure  honesty,  and 
must  have  something  to  do  while  waiting,  give  a  placebo  while 
studying  the  nature  of  the  sore  and  awaiting  developments.  All 
through  syphilis  mercury  has  power,  an  eliminating  and  con- 
trolling power,  if  not  a  curative  one.  The  symptoms  of  syphilis 
are  controlled  by  mercury  better  than  by  any  other  known  drug, 
unless  it  be  the  iocliclic  preparations.  Keyes  has  shown  that 
moderate  doses  of  mercury  continued  for  any  length  of  time  not 
only  do  not  debilitate,  but  act  as  a  tonic  in  health,  in  disease,  in 
syphilis,  augmenting  the  number  of  red  cells  in  the  blood.  In 
the  early  manifestations  of  syphilis  mercury  is  specially  potent. 
Under  its  kindly  influence  the  chancre  heals,  the  early  eruptions 
fade.  Mercury  properly  administered  may  be  taken  for  years 
without  any  injury  to  the  individual,  or  to  his  constitution,  either 
immediate  or  remote  (Keyes). 

Bad  Effects  of  Mercury. — Occasionally  a  patient  appears 
who  tolerates  mercury  badly.  He  may  be  unable  to  take  a  cer- 
tain form — the  protoiodide,  perhaps,  because  it   causes    pain  and 


556  A    COMPENDIUM    OF    PRACTICAL     MEDICIXE. 

diarrhoea — but  can  take  another.  Most  people  tolerate  the  bi- 
chloride kindly  but  a  few  patients  cannot  take  any  form  of  mer- 
cury without  great  mental  and  moral  depression.  Early  spyhilis 
also  produces  great  depression  mentally  and  morally.  When  a 
patient  positively  can  not  take  mercury  at  all  then  we  have  to 
fall  back  upon  the  iodides,  gold,  the  vegetable  remedies,  tonics, 
mineral  waters  and  the  like.  The  other  bad  effects  produced  by 
mercury  are  salivation  and  diarrhoea  with  griping -pain.  Mer- 
curial tremor  and  cachexia  occasionally  occur  after  unjustifiable 
doses  of  the  drug  (see  Salivation). 

Diarrlteea  with  griping  pains  is  apt  to  come  on  in  many 
patients  who  are  fairly  under  the  influence  of  mercury.  If  kept 
up,  the  patient  loses  appetite,  runs  down,  and  fails  to  derive 
benefit  from  his  mercury.  In  these  cases  it  is  better  to  lower  the 
dose  or  change  the  preparation  (Keyes). 

Elimination  of  Mercury  from  the  Body. — Mercury  gets  out 
of  the  body  chiefly  through  the  intestinal  canal,  then  through 
the  salivary  glands,  the  kidneys  and  the  skin.  Mercury  may 
remain  in  the  system  for  five  and  a  half  months  after  the  patient 
has  ceased  taking  it  by  inunction. 

Methods  of  Administering  Mercury. — Are  in  the  order  of 
their  respective  value  to  the  practitioner  :  1.  By  the  stomach. 
2.  Local.     8.  Inunction.     4.  Fumigation.     5.  Hypodermic. 

5.  Hypodermic  Injections. — From  one-sixteenth  to  one- 
eighth  of  a  grain  of  sublimate  dissolved  in  fifteen  minims  of 
water,  is  injected  once  or  twice  daily  under  the  skin.  Abscess 
may  follow  the  puncture,  or  a  hard,  painful  lump,  very  lasting 
sometime.     This  method  can  never  become  popular. 

4.  Fumigation. — This  method  is  an  excellent  one,  but  not 
practical.  It  requires  time  and  care.  It  is  useful  where  prompt 
and  kindly  action  of  mercury  is  aimed  at.  Fumigations  may  be 
taken  daily  for  three  or  four  days,  then  once  a  week  is  usually 
enough  to  keep  up  the  mercurial  effect.  The  best  method  of 
fumigation  is  that  found  in  Turkish  bathing  establishments. 
Calomel  is  the  best  for  fumigation,  because  it  volatilizes  readily. 
About  a  scruple  is  enough  for  a  bath.  The  powder  should  be 
placed  upon  a  piece  of  tin  over  the  spirit-lamp.  The  lamp  and 
tin  are   placed   beneath   a   cane-bottom   chair,    upon    which   the 


syphilis.  557 

patient  sits  naked  and  surrounded  by  blankets  for  fifteen  minutes 
to  naif  hour. 

3.  Inunction. — This  is  perhaps, of  all  the  best  means  of  exhibi- 
ting mercury.  It  spares  the  stomach,  and  is  thorough  and  efficient. 
Its  application  is  very  dirty  and  it  sometimes  produces  a  local 
eruption.  Keyes  thinks  that  the  method  of  inunction  practiced 
at  the  hot  springs  is  decidedly  the  best.  The  patient  takes  a  long 
bath  in  hot  water,  and  after  drying  himself,  an  attendant  rubs  in 
one-eighth  or  one-sixth  of  an  ounce  of  mercurial  ointment.  The 
friction  continues  for  twenty  minutes.  The  next  day  this  is  re- 
peated and  the  effects  watched.  Keyes  does  not  use  the  oleates 
any  more. 

2.  Local  Use  of  Mercury. — Ulcerative  cutaneous  lesions  do 
better  under  iodoform.  Mucous  patches  upon  the  skin  do  well 
if  kept  dry  and  painted  with  bichloride  solution  or  touched  with 
the  acid  nitrate  of  mercury  diluted,  three  to  five  times  and  dusted 
with  calomel.  Cleanliness  is  the  first  requisite  in  the  treatment 
of  lesions  upon  mucous  membranes.  The  teeth  should  be  cleaned, 
tobacco  should  be  stopped  and  soothing  mouth -washes  of  borax, 
alum,  etc.,  may  be  used.  The  mucous  patch  may  be  touched 
with  nitrate  of  silver,  sulphate  of  copper  or  bichloride  solution 
(gr.  ij.  to  Sj)  but  according  to  Keyes  the  acid  nitrate  of  mercury 
pure  and  applied  sparingly  with  the  blunt  end  of  a  glass  rod  is 
the  best.  The  pain  it  produces  on  some  persons  is  a  drawback 
to  its  use. 

1.  Mercury  by  the  Stomach. — For  treating  general  syphilis, 
the  method  by  the  stomach  is  the  best.  In  this  way  it  can  be 
taken  while  traveling  and  without  making  the  patient  conspi- 
cuous to  his  friends,  and  it  can  be  so  used  as  to  act  as  a  tonic  as 
well  as  specific.  The  forms  used  by  the  stomach  are:  the  pro- 
toiodide,  bichloride,  blue-pill,  and  gray  powder.  Keyes  rarely 
uses  the  biniodide,  as  it  is  too  irritating  to  the  intestine.  Gray 
powder  and  blue-pill  are  good  preparations  when  the  protoiodide 
proves  too  irritating  to  the  intestine.  The  bichloride  is  a  very 
tonic  preparation,  and  is  more  prompt  than  the  others. 

Tonic  Method  of  Treatment  by  Mercury. — Consists  in  tin- 
use  of  mercury  in  such  a  way  that  the  mercury,  over  and  above 
its  antisyphilitie  effect,  shall  act  as  atonic — that  is,  shall  increase 


558  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  number  of  the  red  blood- cells,  and  the  general  health  and 
vigor  of  the  patient.  The  outline  of  treatment  is  as  follows: 
The  standard  fractional  dose  being  selected— one -sixth  grain  of 
protiodide,  and  one-thirtieth  grain  bichloride — it  remains  to  find 
the  "full  dose"  and  the  "tonic  dose.'1  The  course  is  commenced 
by  causing  the  patient  to  take  one  granule  or  tablet  of  the  stand- 
ard fractional  dose  immediately  after  each  meal  for  three  days 
— that  is,  three  a  day.  For  the  next  three  days  he  takes  four 
granules  a  day;  then  for  three  days,  five  a  day;  then  for  three 
days,  six  a  day;  then  seven,  and  so  on,  adding  one  granule  to  the 
daily  dose  each  fourth  day,  until  pernicious  medicinal  effects  of 
mercury  begin  to  show  themselves,  which  are,  with  the  protoio- 
dide,  usually  griping  pains  in  the  abdomen,  and  at  least  two  free 
watery  stools  a  day.  When  this  occurs,  write  down  the  daily 
number  of  pills  required  to  produce  it,  and  name  this  number 
the  "full  dose.1' 

Half  the  full  dose  is  the  "tonic  dose,"  and  sometimes  one- 
third  is  all  that  is  required.  The  "  tonic  dose  "  may  be  com- 
menced with  the  idea  of  continuing  it  daily,  month  after  month, 
for  an  average  of  about  two  and  a  half  years.  Under  this  tonic 
dose,  Keyes  says  the  patient  will  often  enjoy  better  health  than 
he  did  before  he  got  his  chancre.  If  new  symptoms  appear  then 
is  the  time  to  add  the  reserve  dose  or  to  throw  in  some  iodide  of 
potassium  for  a  time.  This  tonic  course  of  treatment  is  elimina- 
tive  not  suppressive.  By  this  course  patients  can  be  assured  that 
they  are  taking  mercury  in  the  mildest  manner,  that  it  will  not 
hurt  them  if  they  continue  taking  it  for  several  years,  and  that 
it  will  not  remain  in  the  system  (Keyes). 

Treatment  of  Late  Syphilis. — In  purely  gummatous  deposits 
the  iodides  only  are  required. 

Mixed  Treatment. — When  during  the  tonic  course  there  is  a 
call  on  the  part  of  the  symptoms  for  the  iodides,  they  may  be 
given  while  the  mercury  is  continued. 

The  Iodides. — Often  the  iodides  have  to  be  used  alone  and 
pushed  to  the  point  of  tolerance.  The  iodides  are  agents  of  the 
very  highest  value  in  syphilis,  and  in  purely  gummatous  and 
many  of  the  nervous  symptoms  their  action  in  very  large  doses 
is  most  gratifying.     The  iodide  of  potassium  is  the  most  efficient 


SYPHILIS.  559 

of  the  group.  The  disagreeable  after-taste  left  in  the  mouth  by 
iodide  of  potassium  may  be  best  masked  by  peppermint.  The 
best  time  to  take  the  iodides  is  during  the  third  hour  after  eating, 
when  the  contents  of  the  stomach  are  neutral  and  yet  the  organ 
is  not  empty.  Even  on  an  empty  stomach  the  drug  goes  well  if 
very  largely  diluted  in  milk. 

The  Dose  of  the  Iodides. — There  is  no  limit.  Keyes  has 
given  two  and  a  half  ounces  daily.  Begin  with  the  small  dose 
and  work  up  gradually  to  the  maximum  dose. 

The  Bad  Effects  of  the  Iodides. — The  metallic  taste  in  the 
mouth  is  always  much  complained  of  when  the  dose  runs  high. 
The  bad  effects  are  five  :  1.  Possible  indirect  causation  of  sali- 
vation. 2.  Iodism.  3.  Irritation  of  mucous  membranes.  4. 
Cutaneous  eruptions.  5.  Anaemia  with  nervous  prostration  and 
debility.  6.  Albuminuria.  Moderate  doses  of  arsenic  certainly 
moderate  the  bad  effects  of  the  iodides. 

Duration  of  Treatment. — The  duration  of  the  virulence  of 
the  disease  is  believed  to  subside  in  the  third  year,  and  therefore 
the  rational  period  during  which  to  maintain  continued  treatment 
is  about  the  same.  It  is  impossible  to  say  to  a  given  patient  after 
he  has  followed  this  course  that  he  will  never  have  a  relapse;  but 
he  can  be  told  that  he  has  all  the  guarantee  that  medicine  can 
afford  him,  and  that  if  he  does  have  late  symptoms  the  great 
probability  is  that  they  will  be  mild,  and  will  promptly  yield  to 
a  mixed  treatment  (Keyes). 

Syphilis  of  the  Skin  and  Mucous  Membranes. — The  syphilides 
are  those  manifestations  of  general  syphilis  found  upon  the 
cutaneous  envelope.  Those  occurring  in  secondary  syphilis  are: 
1.  Roseola.  2.  Papular  syphilide.  3.  General  pustular  syphi- 
lide.  4.  Pigmentary  syphilide.  5.  Bullous  syphilide.  6.  Vesi- 
cular syphilide.  7.  Squamous  syphilide.  8.  Turbercular 
syphilide. 

With  these  occur  on  the  mucous  membranes:  1.  Erythema- 
tous patches.  2.  Ulcers.     3.  Mucous  patches.     4.  Scaly  patches. 

The  terftia/ry  lesions  of  the  skin  are:  1.  Ecthyma.  2.  Rupia. 
3.  Pustular  syphilide  in  grouj)S.  4.  Tertian"  ulceration.  5. 
Gummy  subcutaneous  tumor. 


560  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

\Yith  these  occur  on  the  mucous  membrane:  1.  Mucous 
patches.  2.  Scaly  patches.  3.  Deep  chronic  ulcers.  4.  De- 
structive gummy  ulcers  (Keyes). 

TAPE=WORMS. 

Constitute  the  class  cestoda. 

Varieties. — Taenia  saginata,  beef  tape-worm,  is  the  form  most 
common  in  this  country;  taenia  solium  is  occasionally  encountered 
while  the  bothrioeephalus  latus  is  rare  (Bartholow).  There  was 
a  time  when  nearly  every  malady  was  attributed  to  worms. 
Taenia  solium  also  called  "armed  tape-worm  "  is  the  final  devel- 
opment of  an  embryo,  usually  lodged  in  the  flesh  of  some  animal. 
It  is  from  seven  to  thirty  feet  long,  has  a  globular  head  and  flat 
segments  or  joints.  Each  mature  joint  contains  both  male  and 
female  sexual  organs  (hermaphrodite).  An  ordinary  sized  tape- 
worm contains  five  millions  of  ripe  ova. 

The  larval  form  of  this  worm  is  the  cysticercus  cellulosce, 
the  embryo  being  found  in  pork  (measly  pork).  From  one  to 
forty  may  be  present  in  the  same  intestinal  tract,  in  small  intes- 
tine and  may  hang  far  down  into  the  large  intestine;  the  ter- 
minal ripe  segments  are  constantly  falling  off,  and  are  discharged 
with  the  faeces.  In  a  few  months  after  swallowing;  the  embrvo, 
the  tape -worm  reaches  considerable  size. 

Taenia  Saginata,  also  called  "unarmed  tape-worm,11  is 
larger,  stronger,  and  thicker  than  taenia  solium.  The  larval 
form  of  this  worm  is  the  cysticercus  saginata,  the  embryo  being 
found  in  beef. 

The  Bothrioeephalus  latus  is  the  largest  worm  infecting 
man.  This  worm  sometimes  reaches  sixty  feet  in  length.  Its 
color,  unlike  the  others,  is  a  dull  bluish- gray.  Some  suppose  its 
embryo  to  be  found  in  a  fish  or  mollusk  (Loomis). 

Causes. — Since  the  introduction  of  the  Russian  method  of 
curing  diarrhcea  by  the  use  of  finely-scraped  raw  meat,  and  the 
modern  taste  of  eating  rare  steaks,  etc.,  tape-worm  has  become 
more  common.  Their  entrance  into  the  intestinal  tract  is  only 
effected  through  food  and  drink.  Butchers,  and  those  who 
handle  raw  meat,  are  more  subject  to  them  than  others.     Filthy 


TAPE    WORMS.  561 

surroundings,  squalor  and  personal  uncleanliness  are  conditions 
which  favor  their  development.  Tape- worms  occur  at  all  ages. 
Bothriocephalus  latus  is  found  chiefly  in  Scandinavia,  Russia 
and  Poland.  Tamia  solium  occurs  wherever  the  pig  is  domesti- 
cated. Taenia  saginata  is  found  wherever  raw  beef  is  used  for 
food.  The  T<en i a  are  not  found  among  Jews  and  those  who  eat 
no  pork  (Bartholow,  Loomis  and  Flint). 

Symptoms. — Taenia  produces  no  constant  symptoms.  The 
bowels  are  usually  irregular.  There  may  be  colicky  pains  in  the 
abdomen;  the  ap}3etite  is  capricious,  the  face  may  be  pale,  the 
stomach  feels  weak  and  there  is  nausea  and  perhaps  vomiting. 
The  principal  symptoms  are:  emaciation,  notwithstanding  an  in- 
ordinate appetite;  a  feeling  of  lassitude;  palpitation  of  the  heart; 
salivation;  faintness  and  itching  about  the  nose  and  anus.  The 
reflex  symptoms  are  headache,  dizziness,  ringing  in  the  ears,  sud- 
den sweatings  and  grinding  of  the  teeth.  Frequently  a  tape- 
worm produces  absolutely  no  symptoms.  The  diagnosis  can 
only  be  made  by  the  discovery  of  detached  joints  or  segments  of 
the  worms  in  the  faeces.  The  length  of  time  they  remain  in  the 
intestine  is  by  no  means  a  fixed  period;  they  have  been  known  to 
exist  there  ten  to  twelve  years  and  even  longer.  Persons  fre- 
quently fancy  they  have  a  tape -worm.  This  is  one  of  the  notions 
of  a  hypochondriac  and  often  becomes  an  insane  delusion  (Bar- 
tholow, Flint  and  Loomis). 

Treatment. — Prophylaxis  demands  that  all  raw  or  "under- 
done'11 meat  shall  be  avoided.  Measly  pork  should  be  avoided. 
Stockyards  should  be  at  a  distance  from  the  water  supply. 
Green  vegetables,  such  as  lettuce,  should  be  thoroughly  washed 
before  eaten.  Sulphate  of  magnesia  should  be  given  each  morn- 
ing for  two  mornings  before  giving  the  remedy,  the  tseniafuge. 
The  diet  should  consist  of  milk,  steak,  tea  and  toast,  for  the  day 
before  and  during  the  treatment.  German  practitioners  cause 
the  patient  to  take  articles  disagreeable  to  the  parasite — such  as 
garlic,  onions,  and  salt  herring — and  direct  a  plateful  of  herring- 
salad,  a  savory  dish  made  up  of  those  articles,  agreeable  enough 
to  Germans,  but  highly  distasteful  to  tape-worms. 

The  most  successful  treatment  of  tapeworm  Bartholow  has 
any  knowledge  of  is  that  of  an  ignorant  barber,  who  has  a  secret 


562  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

method  which,  seems  never  to  fail.  He  does  not  attempt  any 
preparatory  treatment,  but  administers  his  medicine  (apparently 
a  decoction  of  pomegranate)  in  the  morning,  the  patient  fasting, 
and  retires  from  the  house  with  the  worm  and  his  fee  in  the 
afternoon.  For  the  destruction  of  tape- worms,  many  remedies 
have  been  proposed,  such  as  turpentine,  male  fern  (filix  mas), 
kousso,  pumpkin- seeds,  and  pomegranate  or  its  active  principle 
pelletierine.  Oil  of  turpentine,  in  one-half  or  one-ounce  doses,  is 
one  of  the  oldest  and  is  very  effective.  Male  fern  (filix  mas)  is 
one  of  the  oldest  and  best  known  vermifuges.  The  ethereal 
extract  maybe  given  in  half- drachm  doses,  and  the  oil  in  drachm 
doses.  Another  effective  tseniafuge  is  the  kousso,  the  dried 
flowers  of  a  tree  in  Abyssinia,  where  tape -worm  is  exceedingly 
common.  Half  an  ounce  of  the  powdered  flowers  mixed  with 
water  may  be  given  in  a  dose.  An  emulsion  of  pumpkin- seed 
frequently  acts  efficiently.  Pelleterine  has  been  used  with  in- 
creasing success  since  its  discovery  in  the  proper  doses  (Bartho- 
low,  Flint  and  Loomis). 

TETANUS, 

Or  lock-jaw  is  a  disease  characterized  by  paroxysmal  tonic 
contractions  of  the  voluntary  muscles  and  due  to  exhaltation  of 
the  reflex  function  of  the  spinal  cord  (Bartholow). 

Causes. — Tetanus  is  usually  traumatic  and  may  follow  the 
most  trivial  injury,  as  a  splinter  in  the  finger,  the  prick  of  a  needle, 
the  extraction  of  a  tooth  or  perforating  the  ears  for  ear-rings, 
but  it  is  more  apt  to  develop  after  compound  or  complex  frac- 
tures, lacerated,  crushed  and  punctured  wounds  and  wounds 
complicated  by  the  presence  of  foreign  bodies.  It  may  occur 
after  abortion  or  normal  delivery  and  trismus  nascentium  is  as- 
cribed to  the  wound  at  the  navel.  When  a  wound  is  cicatrizing 
tetanus  is  more  apt  to  occur.  It  is  much  more  common  in  hot 
than  in  temperate  climates.  Exposure  to  wet  and  cold  may  de- 
velop it  (Bartholow  and  Loomis). 

Symptoms, — Tetanus  generally  comes  on  in  from  six  to  twelve 
days  after  the  injury,  but  may  be  delayed  three  or  four  weeks 
or  appear  within  a  few  hours.     In  the  majority  of  cases  it  begins 


TETANUS.  563 

with  stiffness  of  the  muscles  of  the  neck  and  jaw.  The  affection 
is  sometimes  limited  to  these  muscles  and  is  then  distinguished 
as  trismus.  The  jaws  are  firmly  shut  by  rigid  contraction  of 
the  muscles  and  hence  the  affection  is  known  as  lock-jam. 

When  caused  by  cold,  there  is  chilliness,  followed  by  fever, 
and  stiffness  of  the  neck  is  felt.  The  attempt  to  swallow  excites 
cramp  of  the  pharynx,  and  is  difficult  and  painful.  By  degrees 
the  other  muscles  are  involved.  The  limbs  are  extended,  the 
back  arched  (opisthotonos),  less  frequently  the  body  may  be 
bent  forward  (emprosthotonos),  and  still  more  rarely  laterally 
(pleurosthotonos).  The  face  assumes  the  risus  sardonicus. 
Respiration  becomes  difficult.  Spasms  are  excited  by  jars,  by  a 
mere  touch,  a  current  of  air,  etc.  The  pain  is  intense  during  the 
paroxysm.  Between  the  paroxysms  there  are  heavy  ache  and 
soreness.  Just  before  death  the  temperature  may  reach  112°  or 
114°  F.  The  body  is  bathed  in  a  profuse  sweat.  Reflex  excita- 
bility of  the  cord  is  increased  to  a  high  degree  (Bartholow,  Flint 
and  Loomis). 

Differential  Diagnosis. — The  absence  of  headache,  delirium, 
and  coma,  and  a  normal  temperature  in  the  intervals  between 
the  attacks,  will  suffice  to  distinguish  tetanus  from  any  cerebral 
or  cerebro- spinal  inflammation.  Absence  of  coma  distinguishes 
it  from  epilepsy.  In  sti'yolmine  poisoning  the  muscles  of  the 
jaw,  head  and  neck  are  last  and  least  affected  (Loomis). 

Prognosis. — Tetanus  usually  terminates  fatally  before  the 
tenth  day  (Loomis). 

Treatment. — Bartholow  thinks  that  bromide  of  potassium  in 
doses  of  one  to  two  drachms  every  four  hours  until  the  spasms 
cease,  has  been  the  most  successful  agent  thus  far  employed. 
Opium  given  in  large  doses  is  sometimes  successful.  Recently, 
curare,  nitrite  of  amy!,  and  hydrate  of  chloral  (in  forty-grain 
doses)  seem  to  be  the  favorite  drugs.  Loomis  is  of  the  opinion 
that  a  highly  nutritious  diet,  with  alcoholic  stimulation,  is  the 
best  treatment.  Ice  applied  to  the  spine  has  been  found  useful. 
Inhalations  of  ether  and  chloroform  have  given  some  relief. 
Light,  currents  of  air,  and  noise  should  be  excluded  from  the 
patient  (Bartholow,  Flint  and  Loomis). 


564  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

THRUSH. 

Called  also  sprue  or  muguei,  is  an  aphthous  disease  of  the 
epithelium  of  the  mouth  aud  tongue,  due  to  the  growth  of  the 
germs  of  the  thrush -fungus,  the  oidium  albicans.  The  mucous 
membrane  has  numerous  small  round  whitish  spots  which  gives 
to  it  a  curdy  appearance  (Loomis). 

Causes. — In  children  this  disease  occurs  from  birth  to  the 
second  year,  and  is  very  rare  after  that  time  until  adult  life. 
These  parasitic  plants  grow  best  in  the  presence  of  acids,  and 
hence,  the  secretion  of  the  mouth  for  the  tirst  six  or  seven  months 
predisposes  to  it.  Improper  feeding,  indigestion,  gastro- enteritis 
and  want  of  cleanliness  in  the  care  of  nursing- bottles,  spoons, 
etc.,  are  the  principal  causes.  In  adults  thrush  occurs  toward 
the  end  of  any  long  exhausting  disease,  such  as  cancer  or  con- 
sumption (Loomis  and  Smith). 

Symptoms. — The  mouth  becomes  hot  and  painful.  The 
child  will  not  allow  its  mouth  to  be  touched.  There  is  saliva- 
tion which  is  acid.  The  lips  swell  and  become  everted.  Diar- 
rhoea is  frequent.  The  stools  are  acid.  The  acid  causes  an 
erythema  about  the  anus  (Loomis  and  Smith). 

Treatment. — To  avoid  sprue,  the  mouth  of  the  child  should 
be  washed  with  cool  water  each  time  after  nursing.  Borax  is 
the  most  effectual  remedy  for  thrush.  After  each  feeding  the 
mouth  should  be  thoroughly  cleansed  with  borax  and  glycerine, 
or  a  weak  solution  of  carbolic  acid,  and  sulphate  of  soda.  The 
diet  should  be  restricted  to  milk  and  lime-water.  When  there  is 
emaciation,  cod-liver  oil  and  the  lacto phosphate  of  lime  will  be 
of  service.     The  bowels  must  be  regulated  (Loomis  and  Smith). 

TINEA. 

.  Is  the  generic  term  for  skin  diseases  produced  by  fungi. 
There  are  four  diseases  of  the  skin  dependent  upon  the  presence 
of  four  separate  fungous  growths,  viz:  1.  Tinea  favosa.  II. 
Tinea  tricophytina.  III.  Tinea  versicolor.  IV.  Tinea  imbricata. 
There  are  three  varieties  of  tinea  favosa,  or  honey-comb  ring- 
worm, viz:     (a)  Favus  of  hairy  parts,     (b)  Favus  of  non-hairy 


TINEA.  565 

parts,  (c)  Favus  of  nails.  This  disease  which  is  decidedly 
contagious,  usually  makes  its  appearance  in  children,  especially 
in  those  who  are  scrofulous,  debilitated  or  uncleanly.  The  far  us 
of  hairy  parts  is  usually  seen  only  upon  the  scalp.  There  is 
more  or  less  itching.  The  odor  is  characteristic  and  "mousey." 
The  hairs  are  dull,  dry,  discolored  and  easily  extracted.  The 
fungus  may  be  detected  under  microscope.  The  favus  of  non- 
hairy  parts  is  in  the  shape  of  roundish  spots  which  are  bright 
red  in  tint,  and  at  first  very  small  but  soon  reach  the  size  of  a 
crown  piece.  It  is  elevated,  itchy  and  scaly.  It  has  yellow 
streaks.  The  favus  of  the  nails  is  caused  by  scratching  the  af- 
fected part.  The  fungus  gets  under  the  nail  and  it  assumes  a 
yellowish  tint  (Anderson). 

Treatment. — Favus  was  once  thought  to  be  incurable.  De- 
struction of  the  parasite  is  the  only  treatment.  A  solution  of  bi- 
chloride of  mercury  is  a  good  remedy. 

There  are  four  varieties  of  tinea  tricophytina,  or  ringworm, 
viz:  1.  Ringworm  of  the  head.  2.  Ringworm  of  the  body.  3. 
Ringworm  of  the  beard.  4.  Ringworm  of  the  nails. 

Ringworm  of  the  head  is  met  with  almost  exclusively  in 
children.  It  occurs  in  patches  more  or  less  circular  and  never 
implicates  the  whole  head.  The  hairs  are  discolored,  brittle, 
much  thickened  and  twisted  or  broken  off  close  to  the  scalp. 
Itching  is  moderate.     It  is  very  contagious. 

Ringworm  of  the  body  commences  as  little  round,  rose- 
colored,  slightly  elevated  spots,  which  soon  become  scaly  and 
itchy.  The  circles  of  eruption  are  often  several  inches  in  diam- 
eter. It  is  contagious.  Ringworm  of  the  beard,  called  also  tinea 
sycosis,  is  exclusively  met  with  in  adult  males.  It  is  almost 
always  traced  to  a  "foul  shave"  in  a  barber's  shop.  It  is  highly 
contagious.     The  color  of  the  eruption  is  dusky  red  (Anderson). 

Treatment. — The  parts  should  be  scrubbed  night  and  morn- 
ing with  black  soap.  Such  parasiticides  as  bichloride  of 
mercury,  carbolic  acid,  iodine,  etc.,  may  be  used  in  the  proper 
strength  (Anderson). 

Tinea  V<jrxi<u)l<>r  is  an  inflammatory  affection,  generally 
more  or  less  itchy  and  scaly.  There  are  small  pin-head  spots  of 
eruption.      On    scraping   the    surface,  scales    come    away    loaded 


566  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

with  the  parasite.  It  is  a  disease  of  adult  life,  and  never  con- 
genital. The  color  of  the  patches  of  eruption  is  yellow  or  brown. 
The  scales  are  scanty  and  very  fine.  Tinea  versicolor  always 
commences  on  the  trunk.     It  is  contagious  (Anderson ». 

Treatment. — Is  very  simple  and  efficacious.  Generally  the 
application  of  a  solution  of  bichloride  of  mercury  (two  grains  to 
the  ounce  of  water),  or  hyposulphite  of  soda  (5i.  to  the  Si.  of 
water),  to  the  affected  parts  twice  daily,  and  continued  for  some 
time  after  the  eruption  has  disappeared,  is  effectual.  Mercurial 
or  sulphur  vapor  baths  have  the  same  effect.  A  thorough 
scrubbing  of  the  patient  with  black  soap  night  and  morning  in 
a  bath  is  efficacious.  Instead  of  the  black  soap,  the  following 
mixture  may  be  employed  : 

J£     Hydrargyri  perchloridi gr.  xx. 

Saponis  viridis siij. 

Spiritus   rectificati §ij. 

Olei  lavajndulae gtts.  xx. — M. 

Sig. :     To  be  used  night  and  morning,  exactly  in  the  same  way  as 
the  black  soap.  — Anderson. 

Tinea  Imbricata. — Called  also  Tokelan  Ringworm,  is  a 
scaly  disease — much  more  like  ichthyosis  in  its  general  appear- 
ances than  any  other  disease.  The  scales  run  in  concentric 
circles,  and  do  not  extend  deeper  than  the  mucous  layer  of  the 
epidermis.  The  fungi  are  present  in  very  great  abundance 
(Anderson). 

Treatment. — Same  as  ringworm  of  the  body. 

TINNITUS  AURIUM. 

Is  not  a  disease  but  a  symptom  of  disease.  It  consists  of 
imaginary  sounds  and  ringing  noises  in  the  ear.  It  is  a  frequent 
accompaniment  of  cerebral  disorders.  It  is  a  sign  of  little  mo- 
ment, for  it  is  encountered  in  so  many  different  conditions,  such 
as,  disease  of  the  cerebral  vessels,  congestion  of  the  brain,  Meniere's 
disease,  affections  of  the  heart,  anaemia,  etc.  Its  cause  is  some- 
times wax  in  the  meatus.  Various  drugs  will  produce  tinnitus 
aurium  in  some  persons  (Da  Costa). 


tonsilitis.  567 

Treatment. — Discover  and  treat  the  cause  of  the  tinnitus 
aurium.     The  following  formulae  may  be  tried: 

Jfc     Acidi  h}Tdrobrornici  dil  (10  per  cent)  31J. 
Sig. :     One-half  to  a  teaspoonful  in  sweetened  water  thrice  daily. 

— Fothergill. 

I&     Tinct.  cimicifugae ITTcix. 

Aquse §ij . — M. 

Sig. :     A  teaspoonful  thrice  daily.  — Patton. 

TONSILITIS. 

Is  an  inflammation  of  the  tonsil.  The  most  important  varie- 
ties of  tonsilitis  are:  1.  Acute  simple  tonsilitis,  or  catarrhal.  2. 
Follicular  tonsilitis,  or  ulcerative.  3.  Parenchymatous  or  sup- 
purative tonsilitis. 

Acute  simple  tonsilitis  is  characterized  by  redness  with 
moderate  swelling  of  the  tonsils  and  an  inflammatory  exudation 
from  the  mucous  membrane,  composed  of  mucous,  pus-cells,  and 
serum.  This  simple  tonsilitis  is  present  in  most  cases  of  acute 
pharyngitis,  or  ordinary  sore  throat,  and  is  a  trivil  affection. 

Acute  follicular  tonsilitis,  or  ulcerated  sore  throat,  is  of  con- 
siderable clinical  importance.  In  this  affection  the  inflammation 
involves  not  only  the  mucous  membrane  covering  the  surface  of 
the  gland,  but  especially  that  lining  the  crypts.  The  tonsils 
present  little  white  patches.  These  white  deposits  extend  into 
the  crypts  or  follicles.  Acute  follicular  tonsilitis  is  often  at- 
tended by  severe  constitutional  disturbance.  The  symptoms  at 
the  onset  may  be  as  severe  as  in  diphtheria.  There  may  be  a 
chill  or  chilly  sensations.  The  temperature  may  reach  104°  or 
105°  in  twenty-four  to  forty-eight  hours.  There  are  often  head- 
ache, anorexia  and  insomnia.  The  patient  complains  of  dryness 
and  soreness  of  the  throat  and  pain  on  swallowing.  Usually 
within  three  to  five  days  the  fever  and  other  symptoms  subside 
and  recovery  is  rapid.  After  the  attack  there  may  be  marked 
prostration.  The  prognosis  is  always  favorable,  It  may  be  mis- 
taken for  diphtheria. 

Parenchymatous  tonsilitis,  or  ''quinsy  sore  throat,11  some- 
times called  phlegmonous  pharyngitis,  is  an  inflammation  of  the 
parenchyma  of  one  or  both  tonsils.     It  may  terminate  in  resolu- 


568  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tion,  but  usually  it  goes  ou  to  suppuration,  constituting  the  dis- 
ease called  suppurative  tonsilitis  or  quinsy  (Flint  and  Loornis). 

Causes. — Quinsy  is  rare  in  those  under  twelve  years  of  age, 
but  is  more  common  in  youth  than  in  adult  life.  Certain  atmos- 
pheric influences  predispose  to  it.  It  "runs  in  families."  Scro- 
fula and  syphilis  favor  its  development.  Exposure  almost 
always  precedes  an  attack.  One  attack  predisposes  to  others. 
Tonsilitis  often  occurs  with  scarlet  fever,  measles,  and  typhoid 
fever.  Follicular  tonsilitis  with  ulceration  is  usually  preceded 
by  disorders  of  digestion,  and  seems  to  depend  on  this  for  its 
origin.  A  relationship  has  been  supposed  to  exist  between  the 
ovaries  and  tonsils,  but  it  is  by  no  means  well  defined  (Bartho- 
low,  Flint  and  Loomis). 

Symptoms. — There  may  be  a  chill  or  chilly  sensations  at  the 
onset,  followed  by  fever,  (103°  to  105°  F.)  The  tongue  and 
throat  become  dry;  there  are  heat,  pain,  and  swelling  in  the  ton- 
sil; the  fluids  are  often  regurgitated  through  the  nostrils.  Thick 
mucus  is  expectorated.  The  breath  is  offensive,  the  jaws  are 
often  immovable.  There  is  a  peculiar  nasal  tone  to  the  voice. 
The  patient  is  unable  to  sleep,  has  a  sense  of  suffocation,  and 
sometimes  is  delirious.  In  four  or  five  days,  something  is  felt  to 
give  way  in  the  throat,  and  suddenly  the  patient  is  entirely  re- 
lieved by  the  discharge  of  fetid  yellow  pus.  Convalescence  is 
rapid.  The  abscess  in  the  tonsil  may  open  at  one  or  at  several 
points.     Much  suffering  is  experienced  (Flint  and  Loomis). 

Prognosis. — Is  always  good.  Chronic  enlargement  of  the 
tonsil  may  result.  The  entire  duration  of  the  disease  is  eight 
days.  Death  in  rare  instances  may  result  from  suffocation,  ex- 
haustion, or  oedema  glottidis  (Loomis). 

Treatment. — A  saline  laxative  should  inaugurate  the  treat- 
ment unless  the  bowels  are  relaxed.  Tincture  of  aconite -root 
(gtt  i-iij)  may  be  given  every  hour  or  two  for  the  period  pre- 
ceeding  pus-formation.  At  the  onset,  calomel,  in  the  dose  of 
three  to  five  grains,  is  superior  to  all  other  remedies.  When  pus 
has  formed  quinine  is  the  best  agent.  Acetanilid  and  antipyrin 
are  good  remedies  to  reduce  temperature.  Opium  or  its  alka- 
loids should  not  be  given  in  quinsy.  The  local  treatment  is  im- 
portant     A  hot  or  cold  wet  pack  about  the  neck    affords    relief. 


TONSILITIS  —  TOOTHACHE.  569 

A  gargle  of  hot  milk  and  water,  used  every  few  minutes,  lessens 
inflammation  and  swelling.  Sometimes  ice  and  cold  water  are 
more  grateful.  Bicarbonate  of  sodium  in  powder,  placed  on  the 
tonsil  gives  great  relief.  When  suppuration  occurs,  warm  appli- 
cations are  to  be  preferred.  When  the  tonsils  are  much  swollen 
they  may  be  scarified.  When  pus  forms  it  should  be  evacuated. 
Astringent  gargles  at  the  onset  may  in  some  cases  arrest  the  dis- 
ease. Loomis  says  "I  have  been  able  in  a  large  number  of  cases 
to  abort  a  quinsy  by  a  twenty-grain  dose  of  quinine  administered 
at  the  time  of  the  chill  followed  by  a  large  dose  of  bromide  of 
potassium."  Guaiacum  has  long  been  celebrated  for  its  power 
to  arrest  tonsillar  inflammation,  in  scruple  doses.  Fluid  extract 
of  ergot  is  supposed  to  have  specific  power  to  arrest  the  disease 
(Bartholow  and  Loomis). 

TOOTHACHE. 

Is  a  localized  dental  pain,  and  varies  in  character  according 
to  the  part  of  the  tooth  involved.  A  darting  pain  betokens  irri- 
tation and  probable  exposure  of  the  pulp.  A  violent,  throbbing 
pain  points  to  general  inflammation  of  the  pulp.  In  alveolar 
abscess,  the  pain  is  dull  and  throbbing  (Bryant). 

Treatment. — Dentists  employ  arsenic  as  an  escharotic  to 
destroy  the  exposed  sensitive  pulp  of  decayed  teeth.  A  strong 
infusion  of  capsicum  applied  on  lint  to  the  aching  tooth  is  very 
effective.  Chloral,  rubbed  up  with  an  equal  weight  of  camphorT 
and  rubbed  gently  in  externally  or  put  into  the  cavity  of  an 
aching  tooth,  gives  prompt  relief  in  some  cases.  A  few  drops  of 
chloroform  on  cotton-wool,  inserted  into  the  hollow  of  a  decayed 
aching  tooth,  often  gives  permanent  relief.  Equal  parts  of  chlo- 
roform and  creasote  constitute  a  useful  application  in  toothache. 
A  mixture  of  equal  parts  of  collodion  and  carbolic  on  a  small 
piece  of  cotton- wool  inserted  into  the  hollow  painful  tooth  soon 
gives  relief.  A  solution  of  alum  in  nitrous  ether  is  said  to  be  an 
effective  application  in  toothache.  Dr.  Duckworth  reports  that 
toothache  may  be  quickly  allayed  by  holding  a  solution  of  car- 
bonate of  soda  in  the  mouth.  A  drop  or  two  of  oil  of  cloves 
inserted  into  the  cavity  of  an   aching  tooth  soon   stops  the  pain. 


570  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

Xanthoxyluni  (prickly  ash)  is  a  domestic  remedy  for  toothache 
(Bartholow  and  Kinger). 

TYMPANITES. 

Is  not  a  disease  but  a  symptom.  It  is  a  flatulent  distention 
of  the  bowels.  Great  prominence  of  the  abdomen  due  to  flatu- 
lent distention  of  the  bowels,  is,  if  at  all  persistent,  very  apt  to 
be  mistaken  for  ascites.  But  the  large  abdomen  yields  not  a 
dull,  but  everywhere  a  tympanitic  sound  and  there  is  no  fluctua- 
tion. In  most  cases  the  gas  which  causes  the  distention,  is  de- 
rived from  putrefactive  or  fomentative  changes  in  the  ingesta. 
The  accumulation  of  gas  within  the  stomach  occasions  painful  dis- 
tension, and  rarely  may  cause  sudden  death.  The  habit  of  swol- 
lowing  air  may  cause  tympanites  of  the  stomach  (this  corresponds 
to  wind- sucking  in  horses).  An  habitual  tympanites  of  the 
stomach  occasions  in  some  persons,  after  the  ingestion  of  liquid, 
a  succussion  sound  in  walking  resembling  the  sound  frequently 
heard  in  horses.  This  is  a  source  of  much  annoyance  and  morti- 
fication, especially  to  women.  It  may  be  avoided  by  taking  into 
the  stomach  only  very  small  quantities  of  liquid  at  a  time.  Some 
persons  suffer  from  an  habitual  tympanites.  Females  are  more 
liable  to  it  than  males. 

Treatment : 

Jfc     Olei  terebinthime jij.-viij. 

Olei  ricini jfij . 

Vitelli  ovi no.  j . 

Decocti  hordei §viij  .-xvj . — M. 

Ft.  enema. 
Sig.:     Inject  into  the  bowel.  —Bartholow. 

Jfc     Olei  terebinthinse §j. 

Olei  olivse  §iss. 

Camphorse gr.  xx. 

Decocti  avenre Sviij . — M. 

Ft.  enema. 
Sig.:     Inject  into  the  bowel.  — Copeland. 

JSr     Pulv.  capsici gr.  vj.-xxiv. 

Sacchari  lactis gr.  xxx. — M. 

In  pulv.  no.  xii.  div. 
Sig.:     A  powder  every  four  hours.  — Phillips. 


TRICHINOSIS.  571 

TRICHINOSIS. 

Is  a  parasitic  disease.  The  parasite  is  called  trichina  spir? 
alis,  in  tlie  form  of  a  minute  worm,  measuring  about  one-thirty- 
fifth  of  an  inch  in  length,  which  enters  the  human  system  through 
the  intestinal  tract  after  the  ingestion  of  trichinous  flesh  (Loomis). 

Causes. — Trichinosis  in  human  beings  results  almost  exclus- 
ively from  eating  trichinous  pork.  The  raw  flesh  is  most  dan- 
gerous. Sausages,  smoked  ham,  quickly  broiled  ham,  or  any 
form  of  pork  that  has  not  been  subjected  to  a  moist  heat  of  170°, 
is  liable  to  induce  it.  Each  trichina  may  give  birth  to  a  thousand 
young  (Loomis  and  Flint). 

Symptoms. — Are  first  gastro-intestmal  and  then  muscular; 
associated  with  these  there  is  more  or  less  fever.  Nausea,  vom- 
iting, vertigo,  anorexia  and  a  feeling  of  malaise  come  on.  There 
is  almost  always  diarrhoea.  After  a  short  time  there  are  wan- 
dering pains  in  the  limbs,  which  become  stiff  and  painful  to  the 
touch  and  the  muscles  are  swollen  and  rigid.  In  from  four  to 
ten  days  oedema  of  the  eyelids  perhaps  of  the  entire  face  occurs. 
The  temperature  is  101°  to  105°;  the  pulse  110  to  120.  There  is 
photophobia  and  movements  of  the  limbs  or  of  the  eyes  are  ac- 
companied by  excruciating  pain.  The  pain  in  the  limbs  becomes 
so  great  that  the  patient  cannot  sleep.  (Edema  of  the  lower  ex- 
tremities is  common.  The  perspiration  is  copious,  the  diarrhoea 
exhaustive,  the  limbs  are  paralyzed  and  the  patient  lies  in  a  state 
of  utter  helplessness.  Recovery  occurs  in  from  four  to  five 
weeks  after  the  onset  of  the  disease.  Death  may  occur  in  the 
fourth  week  (Loomis  and  Flint). 

Differential  Diagnosis. — Trichinosis  may  be  confounded  with 
typhoid  fever,  but  a  microscopic  examination  of  small  portions 
of  the  muscular  tissue  will   afford  a  positive  diagnosis  (Loomis). 

Treatment. — Preventive  treatment  consists  in  eating  no  pork 
that  has  not  been  so  prepared  as  to  kill  any  trichinae  that  might 
exist.  We  know  of  no  means  of  destroying  the  trichinae  after 
they  have  once  entered  the  muscles.  Purgatives  may  be  given 
early  in  the  disease.  Good  diet,  stimulants,  quinine  and  iron 
are  of  service  (Loomis). 


572  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

TONGUE=TIE. 

Is  occasionally  met  with.  It  is  due  to  a  tying  down  of  the 
tip  of  the  tongue  by  the  frsenum  linguae,  which  prevents  the 
infant  from  projecting  the  organ  beyond  the  gums,  thereby 
interfering  with  suckling  (Bryant). 

Treatment. — It  is  easily  remedied  by  dividing  the  frsenum 
perpendicularly  downward  behind  the  gum  with  a  pair  of 
blunt-pointed  scissors,  the  point  of  the  tongue  being  elevated 
with  the  finger  (Bryant). 

TRACHOMA. 

Called  also  granular  conjunctivitis,  is  characterized  by  hy- 
pertrophy of  the  conjunctiva,  either  in  disseminated  spots  or 
diffused.  The  trachoma  granules  are  small,  rounded  masses  of 
various  sizes.  On  everting  the  lids,  we  find  little  bodies  of  the 
size  of  a  rape -seed  lying  beneath  the  conjunctiva.  The  patient 
complains  of  slight  irritation  of  the  lids  and  inability  to  use  the 
eyes  for  a  long  period;  the  eyes  feel  weak  at  night;  light  is  un- 
pleasant; the  lids  are  sticky  (Noyes). 

Treatment. — Touch  the  lids  lightly  once  a  day  with  a  crystal 
of  sulphate  of  copper  or  alum,  with  solutions  of  tannin  and 
glycerine  (gr.  x.-xxx.  to  oj.),  or  with  a  solution  of  nitrate  of 
silver  (gr.  v.  to  oj).  The  redundant  masses  of  granules  may  be 
squeezed  by  forceps  (Noyes). 

TYPHOID  FEVER. 

Is  an  acute  febrile  affection,  self -limited,  feebly  if  at  all  con- 
tagious, and  characterized  by  a  peculiar  eruption  on  the  abdomen, 
by  a  form  of  diarrhoea,  by  stupor  and  low  delirium,  by  thicken- 
ing and  ulceration  of  Peyer's  patches,  by  infiltration  and  soften- 
ing of  the  associated  mesenteric  glands,  and  by  swollen  spleen 
(Bartholow). 

Typhoid  is  the  most  prevalent  of  all  fevers  except  malarial. 
It  may  be  developed  in  all  latitudes  and  in  all  countries,  but  it 
prevails  more  in  the  temperate  zones  than  in  the  torrid  or  frigid. 
The  Germans  call  it  abdominal  typhus,    gastric   fever,    or    ileo- 


TYPHOID    FEVER.  573 

typhus.  It  is  also  called  common  continued  fever,  enteric  fever 
and  pythog'enic  fever  (Loomis). 

Morbid  Anatomy. — When  the  disease  if  fully  established  the 
blood  becomes  darker  in  color  and  coagulates  imperfectly.  With 
these  blood  changes,  parenchymatous  degeneration  takes  place 
in  the  organs  and  tissues  of  the  body.  But  the  characteristic 
lesions  of  typhoid  fever  are  seated  in  the  lymphatic  structures  of 
the  intestine  namely,  Peyer's  patches  and  the  solitary  follicles. 
Corresponding  to  the  intestinal  changes  are  alterations  in  the 
mesenteric  glands. 

Intestines. — Four  stages  of  the  morbid  process  in  the  intes- 
tine may  be  distinguished  and  they  correspond  very  closely  with 
the  four  weeks  of  the  disease.  In  the  first  week  of  the  disease 
there  are  congestion  and  inflammation  of  the  mucous  membrane 
of  the  small  intestine  with  a  medullary  infiltration  of  Peyer's 
patches  and  the  solitary  follicles.  As  a  result  of  these  processes, 
there  is  hyperemia  and  swelling  of  the  mucous  membranes  and 
the  affected  glands  become  enlarged  and  elevated  from  one  to 
two  lines  above  the  mucous  surface.  These  glands  assume  a 
dark- red  or  reddish -gray  color  marked  with  fine  white  striations 
and  present  the  so-called  "shaven  beard"  appearance.  These 
changes  begin  and  are  most  extensive  in  the  glands  nearest  the 
ileo-csecal  valve.  The  number  of  patches  involved  varies  from 
four  to  five  near  the  valve  to  twenty  or  thirty  throughout  the 
Avhole  intestine.  In  the  second  week  the  hypersemia  and  catarrh 
of  the  mucous  membrane  subside  and  the  swelling  and  infiltra- 
tion  of  the  solitary  follicles  and  Peyer's  patches  increase.  The 
u  shaven  beard  "  appearance  disappears.  During  this  week  ne- 
crotic changes  in  the  swollen  follicles  and  patches  take  place. 
The  casting  off  of  the  necrotic  tissue  results  in  the  formation  of 
the  typhoid  ulcer.  In  the  third  week  the  process  of  ulceration  is 
completed.  The  entire  gland  may  slough  uniformly  and  at  once 
form  the  complete  ulcer. 

Usually  the  sloughing  and  removal  of  the  necrotic  tissue 
does  not  take  place  until  the  third  week  of  the  disease.  The 
necrotic  process  may  extend  and  involve  the  muscular  tissue,  and 
"lid  in  perforation  of  the  peritoneal  covering.  These  ulcers  may 
be   developed   in    the    jejunum,   ileum,  stomach    and    the    large 


574  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

intestine.  In  the  lower  part  of  the  ileum,  at  the  ileo-csecal  valve, 
the  ulcers  are  usually  of  large  size  and  elliptical  with  their  long 
axis  corresponding  to  that  of  the  intestine.  In  the  jejunum, 
stomach  and  large  intestine  they  are  usually  round  and  of  small 
size.  Sometimes  the  ulcers  are  hemorrhagic.  Those  ulcers  re- 
sulting from  necrosis  of  the  solitary  follicles  are  round.  Cases 
have  been  described  in  which  the  ulcers  were  fully  formed  on 
the  seventh  or  eighth  day  of  the  disease.  In  the  fourth  week  the 
process  of  cicatrization  is  commenced.  It  may  begin  in  the 
third  week  of  the  disease  and  continue  during  convalescence. 
Gradually  the  swollen  edges  of  the  ulcers  subside  and  granula- 
tion tissue  springs  up  from  their  base.  The  gland  structure  is 
never  regenerated.  These  cicatrices  have  little  tendency  to  cause 
stenosis  of  the  intestinal  lumen. 

Perforation  of  the  intestine  is  liable  to  occur  in  one  or  more 
of  the  ulcers.  It  occurs  in  about  one  per  cent,  of  the  cases  of 
typhoid  fever,  and  in  about  eight  per  cent,  of  the  deaths  from 
this  disease.  It  is  most  frequent  between  the  third  and  fifth 
week  of  the  disease.  It  is  rarely  caused  by  the  primary  slough- 
ing, but  is  due  to  secondary  ulceration  after  the  separation  of  the 
slough.  The  opening  in  the  peritoneal  coat  may  be  of  consider- 
able size  or  it  may  be  no  larger  than  a  pin's  point.  Profuse 
hemorrhage  may  occur  from  the  primary  sloughing  or  from  the 
secondary  ulceration. 

Mesenteric  Glands. — More  or  less  enlargement  of  the  mesen- 
teric glands  is  always  associated  with  the  intestinal  lesions. 
They  are  secondary  to  the  changes  in  the  intestinal  glands.  The 
enlarged  glands  vary  in  size  from  that  of  a  hazel-nut  to  a  small 
hen's  egg.  In  rare  instances  these  glands  slough  and  cause  peri- 
tonitis. 

Spleen. — The  organ  in  which  parenchymatous  degeneration 
occurs  earliest  and  most  extensively  is  the  spleen.  It  is  enlarged 
often  two  or  three  times  its  normal  size.  The  enlargement  goes 
on  rapidly  until  the  third  week,  and  is  due  to  congestion  and  to 
hyperplasia  of  the  cellular  elements.  It  is  dark-red  in  color  and 
softened.  Hemorrhagic  infarctions  and  rupture  of  the  capsule 
of  the  spleen  may  take  place.     These  changes  in  the  spleen  take 


TYPHOID    FEVEK.  575 

place,  in  a  greater  or  less  degree,  in  ninety -eight  cases  out  of  every 
hundred. 

Liver. — The  liver  is  usually  somewhat  swollen,  pale,  and 
softened.  The  hepatic  cells  are  in  a  condition  of  parenchymatous 
degeneration. 

Kidneys. — Parenchymatous  degeneration  of  the  renal  epi- 
thelium is  the  rule.     An  acute  nephritis  may  occur. 

Heart. — The  heart  becomes  soft  and  flabby,  and  is  of  a 
grayish  or  brown  color.  The  parenchymatous  changes  which 
take  place  in  the  heart  are  more  marked  than  those  of  any  other 
organ  except  the  spleen.  The  heart  loses  its  normal  outline,  and 
when  removed  from  the  body  the  walls  of  its  cavities  readily  fall 
together.  Vegetations  sometimes  form  on  the  valves  and  chords© 
tendinege  of  the  heart,  and  in  some  cases  the  first  sound  will  be 
absent. 

Lungs. — Changes  in  the  lungs  are  present  in  nearly  all  cases 
of  typhoid  fever.  Congestion  and  inflammation  of  the  bronchial 
mucous  membrane  are  so  constantly  present,  that  Dr.  Stokes  pro- 
posed to  call  typhoid  fever  bronchial  typhus.  Hypostatic  con- 
gestion and  pulmonary  oedema  are  common.  Pneumonia  is  a 
frequent  complication. 

Larynx. — Ulcerations  of  the  larynx,  the  mucous  membrane 
of  the  mouth  and  pharynx  may  occur. 

Salivary  Glands. — The  salivary  glands  enlarge,  become 
firm  and  tense,  and  there  are  a  proliferation  and  parenchymatous 
degeneration  of  their  cells.  These  changes  cause  a  diminished 
salivary  secretion  which  is  so  marked  and  constant  in  typhoid. 
Abscess  of  the  parotid  gland  may  occur  in  tyjDhoid. 

Brain  and  Nervous  System. — No  changes  have  been  dis- 
covered in  the  central  nervous  system  to  explain  the  mental  dis- 
turbance which  characterizes  this  disease.  But  it  is  reasonable 
to  infer  that  in  a  disease,  where  such  severe  functional  distur- 
bances exist,  there  must  be  constant  and  definite  parenchymatous 
changes. 

Stomach. — Softening  and  degeneration  of  the  glandular 
structure  takes  place  in  the  stomach  and  this  gives  rise  to  dis- 
turbance of  digestion. 


576  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Muscles-. — The  voluntary  muscles  undergo  a  hyaline  or 
waxy  degeneration  (Flint  and  Loomis). 

Causes. — Typhoid  is  endemic  in  every  quarter  of  the  globe. 
It  is  possible  for  it  to  prevail  as  an  epidemic.  It  prevails  more 
in  the  autumn  than  in  any  other  season  of  the  year  and  for  this 
reason  it  has  been  called  autumnal  fever.  It  is  stated  that  a 
warm,  dry  summer  favors  the  occurrence  of  the  disease  in  the  fol- 
lowing autumn.  Age  must  be  regarded  as  a  predisposing  cause 
of  typhocl  fever.  It  occurs  most  frequently  between  the  ages  of 
fifteen  and  twenty- five,  next  between  ten  and  fifteen  and  next  be- 
tween twenty- five  and  thirty.  It  is  rare  in  infancy  and  after 
fifty.  As  a  rule  persons  are  in  good  health  when  attacked. 
Pregnant  women  when  attacked  with  typhoid  fever  generally 
abort.  Some  persous  are  more  susceptible  to  the  typhoid  pois- 
on than  others.  The  typhoid  bacillus  is  the  specific  cause  of 
the  disease.  This  micro-organism  may  grow  readily  outside  of 
the  body,  as  in  the  soil,  on  vegetables,  milk,  meat-infusions,  or  in 
liquids  containing  sufficient  nutriment,  and  by  the  formation  of 
spores  it  may  preserve  its  vitality  for  a  long  time.  There  is  no 
evidence  that  the  typhoid  bacillus  exists  in  the  exhalations  from 
the  patient.  Typhoid  fever  is  communicable  but  not  in  the  same 
way  as  the  strictly  contagious  diseases,  such  as  small-pox,  scarlet 
fever,  etc. 

Washerwomen  frequently  contract  the  disease  from  washing 
linen  soiled  with  typhoid  excreta.  It  is  probable  that  the 
typhoid  stools  are  the  chief  source  of  infection  of  a  locality  in 
which  the  disease  becomes  endemic.  The  following  instance 
proves  this:  A  stranger  ill  with  typhoid  fever  came  to  a  little 
settlement  called  North  Boston,  consisting  of  nine  families.  Up 
to  this  time  typhoid  fever  had  never  been  known  in  that  neigh- 
borhood. In  a  few  days  the  stranger  died,  and  in  a  month,  more 
than  half  the  population,  numbering  forty-three,  had  been 
affected,  and  ten  died.  Of  the  nine  families,  one  family  escaped 
which  obtained  its  water  from  a  source  different  from  the  others, 
which  used  a  common  well.  The  typhoid  bacilli  have  been 
found  in  the  drinking-water  of  regions  where  typhoid  was  pre- 
vailing as  an  epidemic.  Such  water  may  be  perfectly  clear  and 
apparently  pure.     Sometimes  the  water  of  a  well  used  for  drink- 


TYPHOID    FEVER.  577 

iiig  purposes  becomes  infected  by  a  cormnunication  or  leakage 
between  it  and  a  privy-vault,  cess-pool,  sewer,  or  drain.  A 
number  of  typhoid  epidemics  have  been  traced  to  the  milk- 
supply.  Here  it  is  probable  that  the  vehicle  of  infection  is  the 
water  used  in  cleansing  the  cans  or  in  diluting  the  milk.  The 
period  of  incubation  varies  frorn  fourteen  to  twenty  days  (Flint 
and  Loomis). 

Symptoms. — Typhoid  fever  is  developed  gradually  as  a  rule, 
and  is  insidious  usually  in  its  approach.  The  j)atient  feels 
uneasy  and  uncomfortable,  has  no  pain,  but  feels  that  he  is  about 
to  be  sick.  The  premonitory  symptoms  are  :  Headache,  more 
or  less  aching  of  the  limbs,  "a  tired  feeling  all  over,"  chilly  sen- 
sations, loss  of  appetite,  occasional  nausea  and  vomiting,  epistaxis 
in  most  cases,  diarrhoea  or  constipation.  By  the  fifth  or  sixth 
day  the  patient  is  compelled  to  take  to  his  bed.  Countenance 
has  nothing  peculiar  at  first,  except  it  is  flushed,  but  later  the 
expression  is  dull  and  there  is  an  appearance  of  stupidity.  B)r 
the  second  week,  there  is  a  pale,  olive,  leaden  look,  and  usually 
there  is  a  small  rose -colored  spot  in  the  centre  of  each  cheek. 
The  face  does  not  assume  the  dark  mahogany  color  seen  in 
typhus,  but  in  the  advanced  stages  of  the  fever  it  has  more  of 
the  hectic  flush  of  phthisis.  The  whole  surface  presents  a  slight 
capillary  congestion,  like  that  jxroduced  by  the  action  of  cold, 
and  in  some  cases  the  hue  of  the  surface  is  slightly  dusky.  This 
capillary  congestion  is  caused  by  paresis  of  the  peripheral 
arteries. 

Nervous  System. — - -The  symptoms  referable  to  the  nervous 
system  are:  1.  Headache  which  is  more  or  less  complained  of 
during  the  first  week,  but  usually  ceases  during  the  second  week. 
It  is  not  violent,  but  a  dull  heavy  pain.  Pain  in  the  back  and 
limbs,  and  a  general  aching  of  the  whole  body  is  also  com- 
plained of. 

Delirium  is  manifested  in  the  majority  of  cases.  The  de- 
lirum  rarely  comes  on  before  the  second  week  of  the  fever  and  is 
most  active  at  night.  The  delirum  is  usually  the  "low-mutter- 
ing,'" but  it  may  be  violent.  Persisting,  active  delirium  is  an 
extremely  unfavorable  symptom.  The  mental  condition  is  char- 
acterized by  hebetude,  indifference,  and  inanimation.  Sensibility 


578  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

is  diminished  and  perception  blunted.  The  state  in  which  the 
patient  may  be  said  to  be  both  sleeping  and  wakeful,  is  called 
coma-vigil.  Other  nervous  symptoms  are:  grasping  at  invisible 
objects  or  carphologia,  pulling  up  of  the  bed  linen,  visible 
twitchings  of  the  muscles  of  the  face  and  of  the  extremities,  sub- 
sultus  tendinum,  rigidity  of  the  muscles  of  the  neck  or  extremi- 
ties and  convulsions.     These  denote  gravity  of  the  disease. 

Digestive  System. — Anorexia  is  the  rule.  Thirst  is  promin- 
ent. The  tongue  from  the  very  outset  is  covered  with  a  light, 
white  coat.  At  the  end  of  the  first  week  it  becomes  red  upon 
its  sides  and  tip  and  dry  in  centre.  In  the  second  and  third 
weeks  the  tongue  becomes  more  heavily  coated,  the  coating 
becomes  brown  and  dry,  and  sordes  collect  on  the  teeth.  At  any 
period  in  the  course  of  the  disease  the  tongue  may  suddenly  clear 
off  and  present  a  shiny  red,  beef- colored  appearance.  The  tongue 
and  lips  may  become  dry,  cracked,  and  fissured  and  bleed. 
Nausea  and  vomiting  are  quite  common  during  the  first  week  of 
the  fever.  Diarrhoea  is  one  of  the  characteristic  symptoms,  but 
is  not  always  present.  The  discharges  are  of  a  yellowish -green 
color,  described  as  "pea-soup  discharges."  Sometimes  they 
resemble  coffee-grounds.  The  diarrhoea  usually  appears  the 
second  week,  but  in  some  cases  it  is  present  at  the  very  outset  of 
the  disease  and  in  others  it  does  not  appear  until  the  third  week. 

Intestinal  Hemorrhage. — Hemorrhage  from  the  bowels 
occurs  in  about  five  per  cent,  of  the  cases.  It  may  be  slight, 
moderate,  or  profuse.  These  hemorrhages  usually  occur  in  the 
second  and  third  weeks,  and  are  accompanied  by  a  sudden  fall 
of  temperature. 

These  three  symptoms,  namely,  meteorism,  or  tympanites, 
iliac  tenderness  and  gurgling,  especially  the  two  former  con- 
joined with  diarrhoea  and  ochre -colored  discharges — form  a 
group  of  symptoms  highly  diagnostic  of  this  form  of  fever.  They 
may  all  be  absent. 

Perforation. — Perforation  of  the  intestine  takes  place  in  be- 
tween one  and  two  per  cent,  of  all  cases,  and  in  ten  per  cent,  of 
fatal  cases.  It  takes  place  late  in  the  disease  or  during  convales- 
cence and  sometimes  even  after  apparent  recovery.  It  occurs  as 
often  in  mild  as  in  severe  cases.     Perforation   gives   rise   to    per- 


TYPHOID    FEVER.  579 

itonitis,  which  is  generally  developed  abruptly.  The  sudden  oc- 
currence of  pain  diffused  over  the  abdomen,  increased  tympanitic 
distension  rigidity  of  the  abdominal  walls,  great  prostration,  a 
rapid,  feeble  pulse,  a  sunken  anxious  expression  of  countenance, 
nausea  and  vomiting  quickly  followed  by  coldness  and  blueness 
of  the  extremities  and  other  signs  of  collapse  point  to  peritonitis 
from  perforation.  Peritonitis  does  not  invariably  denote  perfora- 
tion.    It  may  be  caused  by  rupture  of  a  mesenteric  gland. 

Shin. — Of  the  symptoms  referable  to  the  skin,  the  most  im- 
portant is  a  characteristic  eruption.  It  makes  its  appearance  be- 
tween the  sixth  and  twelfth  days  of  the  disease,  and  remains  visi- 
ble from  eight  to  fourteen  clays.  It  consists  of  isolated  papules 
generally  limited  to  the  trunk,  of  a  rose  or  pink  color,  called  by 
Louis  lenticular  rose-colored  spots.  The  spots  are  slightly  ele- 
vated and  the  redness  momentarily  disappears  on  light  pressure. 
The  number  of  spots  varies  from  two  or  three  to  many.  Each 
spot  remains  visible  for  three  days  and  then  disappears.  The 
eruption  is  not  invariably  present.  Jenner  states  that  he  found 
the  eruption  present  in  one  hundred  and  forty -eight  out  of  one 
hundred  and  fifty -two  cases.  Bed-sores  and  gangrene  are  liable 
to  occur  in  situations  exposed  to  pressure. 

Respiratory  System. — Slight  or  moderate  cough  is  almost 
invariably  present,  proceeding  from  sub -acute  bronchitis. 
Pneumonia  is  a  frequent  complication.  Hypostatic  congestion 
and  oedema  of  the  posterior  portions  of  both  lungs  are  incident 
to  the  feeble  circulation  in  the  latter  part  of  the  disease. 
Epistaxis  is  a  symptom  of  diagnostic  value  early  in  the   disease. 

Pulse. — The  danger  is  usually  considerable  if  the  pulse  for 
many  days  exceed  120  per  minute.  A  sudden  and  considerable 
increase  of  frequency  of  the  pulse  often  denotes  the  occurrence 
of  pneumonia  or  peritonitis.  The  pulse  is  quick  and  vibratory 
and  often  dicrotic.  Failure  of  heart- power  is  indicated  by  an 
increase  in  the  frequency  and  feebleness  of  the  pulse. 

Temperature. — There  is  a  daily  increase  of  temperature  for 
the  first  five  or  eight  days.  This  gradual  rise  of  temperature 
from  day  to  day  during  the  first  week  is  diagnostic  of  typhoid 
fever.  There  are  morning  remissions  and  evening  exacerbations. 
The  temperature  of  typhoid  fever  does  not   always  pursue  the 


580  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

typical  course.  The  temperature  may  reach  its  acme  by  the  end 
of  the  third  day,  and  may  be  of  a  remittent  or  intermittent  type. 
A  high  elevation  of  temperature  in  the  morning,  106°  to  108°  F., 
indicates  the  approach  of  death.  A  sudden  and  considerable  fall 
of  temperature,  other  symptoms  not  denoting  convalescence  or 
improvement,  is  unfavorable.  This  often  indicates  hemorrhage 
from  the  bowels. 

Special  Senses. — The  eye  assumes  a  dull  expression  and  the 
pupil  is  dilated.  The  sense  of  heariug  is  always  more  or  less 
impaired.  The  sense  of  taste  is  perverted  and  patients  are  unable 
to  distinguish  between  bitter  and  sweet.  Hypercesthesia  may  be 
present  in  hysterical  females. 

Emaciation  is  more  marked  and  rapid  in  typhoid  than  in 
any  other  form  of  fever. 

Mild  Typhoid  Fever. — -In  the  mild  type,  the  fever  runs  its 
regular  course  but  is  of  low  grade.  Some  of  these  cases  are  so 
mild  that  the  patients  are  not  confined  to  the  bed,  and  are  called 
"walking  cases"  of  typhoid  fever.  All  the  symptoms  of  these 
cases  are  mild.  These  patients  should  take  to  the  bed  and  re- 
main there  until  convalescence  is  established.  The  abortive  form 
of  typhoid  fever  is  ushered  in  with  all  the  symptoms  of  a  typical 
case;  but  by  the  end  of  the  second  week  the  patient  passes  on  to 
a,  state  of  complete  convalescence.  If  only  a  moderate  amount  of 
typhoid  poison  is  introduced  into  the  system,  a  mild  or  an  abor- 
tive type  of  fever  will  be  developed. 

Duration  of  Typhoid. — Of  forty-two  cases  ending  in  recovery 
analyzed  by  Flint  the  average  duration  was  sixteen  days.  The 
maximum  duration  was  twenty- eight  days  and  the  minimum  five 
days.  Of  forty-five  fatal  cases  of  Flint's  the  mean  duration  was 
a  fraction  more  than  fourteen  days,  the  maximum  being  twenty 
and  the  minimum  nine  days.  The  average  duration  of  conva- 
lescence is  between  one  and  two  weeks.  A  temporary  fever  often 
accompanies  the  change  of  diet  from  liquid  to  solid  animal  food. 

Relapses  of  typhoid  fever  sometimes  occur.  A  return  of  the 
fever  may  take  place  after  ten  days  to  two  weeks  from  the  date 
of  convalescence,  and  the  patient  passes  through  a  second  career, 
the  eruption  and  other  characteristic  symptoms  being  reproduced. 
The  duration  of  the   second    career    is    usually  shorter    and    the 


TYPHOID    FEVER.  581 

severity  greater  than  the  first,  but  a  fatal  termination  is  rare. 
The  cause  of  the  relapse  is  not  known.  Some  hold  that  all  re- 
lapses depend  upon  a  new  infection.  Others  hold  that  a  part  of 
the  typhoid  poison  has  remained  in  the  system,  undeveloped  dur- 
ing the  primary  attack.  In  some  cases,  apparently,  the  relapse 
has  been  brought  on  by  indiscretion  in  diet,  or  exercise  (Bartho- 
low,  Flint  and  Loomis). 

Differential  Diagnosis. — The  presence  of  fever  with  evening 
exacerbations  and  morning  remissions,  headache,  diarrhoea,  ab- 
dominal tenderness,  and  the  presence  of  the  characteristic  rose- 
colored  spots  are  sufficient  for  a  diagnosis.  Typhoid  fever  may 
be  confounded  with  typhus  and  releasing  fevers,  continued  ma- 
hi  rial  fever,  mute  tuberculosis,  pyaemia,  septicaemia,  pneumonia, 
</astro-enteritis,  trichinosis,  diffuse  parenchymatous  hepatitis, 
and  acute  meningitis. 

Typhus  fever  is  sudden  in  its  advent,  while  typhoid  is  slowly 
developed. 

In  typhus  fever,  there  is  a  chill  at  the  commencement,  and 
severe  pain  in  the  head;  great  muscular  weakness;  the  tempera- 
ture rises  rapidly  to  104°  or  105°  F.,  before  the  end  of  the  second 
day;  emaciation  is  slight;  the  eruption  appears  upon  the  arms 
and  chest  on  the  fifth  or  sixth  day;  the  spots  are  numerous  and 
of  a  dark  pinkish  hue;  constipation  is  the  rule;  the  abdominal 
symptoms  of  typhoid  are  never  present  in  typhus  fever.  Typhus 
fever  is  contagious,  typhoid  fever  is  non-contagious.  Typhus  is 
generally  epidemic,  typhoid  is  always  endemic.  In  typhus,  the 
dusky  face,  contracted  pupils,  and  peculiar  smell  will  distinguish 
it  from  typhoid. 

In  typhoid,  the  slow  invasion,  the  "  step-ladder11  rise  in  tem- 
perature, the  eruption,  the  characteristic  diarrhoea,  and  the  con- 
tinuance without  remission  or  intermission  will  be  sufficient  to 
distinguish  it  from  relapsing  fever. 

Acute  miliary  tuberculosis  is  to  be  discriminated  from 
typhoid  by  the  notable  frequency  of  the  respirations,  the  prom- 
inence of  the  cough,  haemoptysis  in  some  cases,  the  abundance  of 
sub-crepitant  rales;  by  marked  lividity  and  presence  of  choroid 
tubercles,  and  by  the  absence  of  the  abdominal  and  other  events 
of  typhoid. 


582  A    COMPENDIUM    OF    PRACTICAL     MEDICINE 

Acute  meningitis  is  distinguished  from  typhoid  by  more  in- 
tense headache  by  intolerance  of  light  and  sounds,  early  and  ac- 
tive delirium  by  frequent  vomiting,  by  rigidity  of  the  muscles  at 
the  bach  of  the  neck  and  by  somnolencv  and  coma  succeeding 
the  delirium  and  by  depressed  abdomen.  In  pyaemia  and  sep- 
ticaemia the  surface  of  the  body  has  a  jaundiced  hue,  there  are 
no  spots,  the  fever  is  irregular,  recurring  chills  followed  by  jn*o- 
fuse  sweatings  take  place  early.  Pneumonia  with  typhoid  symp- 
toms is  sometimes  mistaken  for  typhoid  fever.  The  physical 
signs,  the  cough,  the  characteristic  pneumonic  expectoration,  no 
eruption,  etc.,  will  distinguish  it  from  typhoid  (Bartholow,  Flint 
and  Loomis). 

Prognosis. — Death  may  occur  at  any  stage  of  this  fever.  The 
average  mortality  from  typhoid  is  about  ten  per  cent.  The  prog- 
nosis is  always  bad  in  those  who  are  fat.  Complications  render 
the  prognosis  more  unfavorable.  Death  rarely  occurs  before  the 
fourteenth  day.  The  direct  causes  of  death  are:  toxcemia, 
asthenia-,  suppression  of  ike  urine,  cedema  of  the  lungs,  exhaustive 
diarrhoea,  intestinal  hemorrhage  or  perforation  and  peritonitis 
(Bartholow,  Flint  and  Loomis). 

Treatment. — The  typhoid  stools  should  be  thoroughly  disin- 
fected as  soon  as  passed,  and  should  never  be  emptied  into  a 
privy  or  water-closet,  but  into  trenches.  The  bed-linen  should 
be  disinfected  and  kept  scrupulously  clean.  Typhoid  fever 
cannot  be  aborted  by  any  remedy  known.  The  patient  should 
be  placed  in  a  large  and  well- ventilated  apartment.  Only  the 
nurse  and  attendants  should  be  allowed  in  the  room.  Milk  is 
the  proper  diet,  and  fruit*  are  not  to  he  allowed  in  any  r<ts<-. 
Frequent  sponging  of  the  body  with  tepid  water  will  be  of 
service.  When  the  temperature  reaches  104°  or  more,  sponge 
the  body  with  cold  water.  Of  the  internal  antipyretics,  Loomis 
prefers  antifebrin  in  five  to  ten  grain  doses  three  times  daily. 

Stimulants. — When  signs  of  failure  of  heart-power  begin  to 
manifest  themselves,  stimulants  are  indicated.  If  under  their 
use  the  tongue  becomes  dry,  the  patient  more  restless,  the  deli- 
rium more  active,  the  temperature  higher,  and  the  pulse  more 
frequent,  it  is  very  certain  that  stimulants  are  contraindicated: 
and  vice  versa.     Bartholow's  experience  is.  that  the  administra- 


TYPHOID  FEVER TYPHI'S  FEVER.  583 

tion  of  iodine  has  a  favorable  effect  on  the  course  of  the  disease, 
and  he  has  used  with  decided  success  the  combination  of  iodine 
and  carbolic  acid  (jfc  Tinct.  iodi  5ii.,  acid  carbolici  5i. — M.  Sig.: 
One  to  three  drops  three  times  a  day). 

Diarrhoea. — For  the  diarrhoea,  there  is  but  one  remedy 
which  can  be  relied  upon,  and  that  is  opium. 

Tympanites. — Turpentine  stupes  to  the  abdomen,  and  tur- 
pentine internally  and  by  rectum  will  give  relief  to  the  tym- 
panites. 

Intestinal  Hemorrhage. — Can  best  be  controlled  by  an  ice- 
bag  to  the  abdomen,  and  the  administration  of  opium  in  small 
doses  frequently. 

Peritonitis. — Is  best  treated  by  opium. 

For  the  bronchitis,  carbonate  of  ammonia  is  very  effective. 
For  the  active  delirium,  opium  and  sedative  remedies.  For  bed- 
sores, cleanliness  and  the  proper  dressings  (Bartholow,  Flint  and 
Loomis). 

TYPHUS  FEVER. 

Is  a  febrile  affection,  self-limited,  contagious,  usually  pre- 
vails epidemically,  and  characterized  by  profound  adynamia,  a 
peculiar  petechial  eruption,  favorable  cases  terminating  by  crisis 
at  the  end  of  the  second  week.  It  has  received  a  great  variety 
of  names,  such  as  ship  fever,,  hospital  fever,  jail  fever,  camp  fever, 
petechial  fever,  putrid  fever,  Irish  ague,  brain  fever,  spotted  fever, 
continued  fever,  etc.  (Bartholow  and  Loomis). 

Morbid  Anatomy. — In  typhus  the  abdominal  lesions  which 
are  characteristic  of  typhoid  fever  are  wanting.  The  small  in- 
testine may  have  the  shaven-beard  appearance.  There  are  no 
lesions  peculiar  to  the  disease  and  constantly  present.  The  spleen 
is  usually  large,  soft,  and  of  a  dark,  bluish -red  color.  The  blood 
is  unnaturally  dark  and  fluid.  Hypostatic  congestion  of  the 
lungs,  bronchitis,  lobular  pneumonia,  pulmonary  oedema,  cere- 
bral congestion,  and  parenchymatous  degenerations  are  frequent 
(Flint  and  Loomis  ). 

Causes. — Typhus  is  seen  in  this  country  only  at  our  seaport 
towns.  It  depends  upon  a  specific  poison,  of  whose  exact  nature 
we  are  ignorant.     This  poison  is  communicated  from  the  sick  to 


584  A    COMPENDIUM    OF    PRACTICAL     MEDICIJSTE. 

the  healthy  mainly  by  personal  contagion — that  is,  the  recipient 
of  the  poison  ninst  be  brought  in  contact  with  the  exhalations  of 
the  infected  person.  Where  there  is  free  ventilation,  contagion 
is  confined  to  narrow  limits.  Typhus  poison  passes  into  the  body 
mainly  through  the  respired  air.  This  disease  is  not  indigenous 
to  this  country.  It  is  imported  from  Ireland,  Italy,  and  Russia, 
which  seem  to  be  the  great  endemic  centres. 

It  has  been  proved  by  actual  experiment  that  the  contagious 
distance  of  small -pox  in  the  open  air,  does  not  exceed  two  and 
one -half  feet  and  it  would  seem  that  the  contagious  distance  of 
typhus  fever  is  even  less.  It  requires  the  concentration  of  the 
poison  and  prolonged  exposure  to  render  it  infectious.  The  per- 
iod of  incubation  is  about  fourteen  days.  A  single  patient  in  a 
spacious,  well -ventilated  apartment  seldom  communicates  the 
disease.  Typhus  fever  prevailed  in  New  York  City  as  an  epi- 
demic in  1861  to  1864;  1428  cases  were  admitted  into  Bellevue 
Hospital  during  this  time  (Bartholow,  Flint  and  Loomis). 

Symptoms. — Its  advent  is  usually  sudden.  As  a  rule,  the 
onset  is  marked  by  a  distinct  chill,  followed  by  a  severe  and 
steadily  increasiDg  headache  and  by  pain  in  the  back  and  .limbs 
and  by  great  muscular  weakness.  The  face  has  a  dusky  or 
dingy  hue.  In  some  cases  there  are  coma -vigil  delirium,  stupor, 
p'm-liole  pupil  and  convulsions.  The  tongue  is  covered  with  a 
thick  brown  or  black  coating.  Sordes  collect  on  teeth  and  lips. 
A  characteristic  eruption  appears  about  the  third  to  the  fifth 
day.  It  is  a  macular  not  a  papular  eruption.  The  spots  become 
of  a  dull,  dingy  or  dark- red  color,  and  do  not  disappear  on  pres- 
sure. They  are  smaller  than  the  papules  of  typhoid.  They  do 
not  come  and  go  like  the  rose  papules  of  typhoid.  The  odor 
from  typhus  patients  is  stated  to  be  characteristic.  The  temper- 
ature the  first  day  may  rise  to  104°  or  105°  F.,  and  remain  so  the 
first  week.  The  pulse  ranges  from  100  to  130.  Loss  of  muscu- 
lar strength  is  so  great  that  the  patient  is  unable  to  turn  in  bed. 
The  duration  of  typhus  is  about  fourteen  days.  One  attack 
serves,  to  exempt  from  future  attacks  (Bartholow,  Flint  and 
Loomis). 

Prognosis. — In  certain  epidemics  the  mortality  runs  as  high 
as  forty  to  fifty  per  cent.     Average  fifteen  per  cent. 


ULCERS    AND    SOEES.  5S5 

Treatment. — The  same  means  of  treatment  pursued  in  typhoid 
are  equally  applicable  to  typhus  fever  (See  treatment  of  ty- 
phoid) (Bartholow). 

ULCERS  AND  SORES. 

Ulceration  is  the  result  of  an  inflammatory  process  by 
which  a  sore  or  chasm  is  produced.  An  ulcer  is  a  loss  of  sub- 
stance without  a  tendency  to  heal.  An  ulcer  is  molecular  necro- 
sis, the  nutrition  of  the  tissue  being  so  disturbed  as  to  allow  the 
chemical  or  disintegrating  changes  to  have  their  way.  A  sore  is 
a  chasm,  a  solution  of  continuity,  caused  by  ulceration,  the  result 
of  injury  or  otherwise,  upon  an  external  or  internal  surface  of 
the  body.  When  a  sore  is  being  formed  or  is  spreading  by  the 
process  of  ulceration,  an  ulcer  is  said  to  exist;  when  the  ulcera- 
tion has  ceased,  a  sore  remains  (Bryant  and  Dennis). 

Situation. — Ulcers  are  found  upon  the  skin,  mucous  mem- 
brane, serous  membrane,  and  inner  wall  of  blood-vessels  (Dennis). 
Varieties  According  to  Condition  of  Ulcer. — Ulcers  may  be 
healthy,  inflamed,  weak,  indolent,  sloughing  from  excess  of  in- 
dolence, or  irritable. 

Causes. — Axe  predisposing  and  exciting.  Predisposing  causes 
are:     1.  Age.     2.  Malnutrition.     3.  Poor  blood  supply. 

The  exciting  causes  are:  1.  Injury — mechanical,  chemical, 
and  thermic.  Mechanical  injury,  as  a  splint,  pressure,  blowsT 
etc.  Chemical  injury,  as  the  extravasation  of  urine.  Thermic 
injury,  as  frost-bite,  burns,  lightning,  etc.  2.  Disturbances  in 
the  circulation,  as  varicose  veins,  atheroma  of  the  vessels,  weak- 
ened heart  action.  3.  Disturbances  in  the  nutrition.  These  may 
be  local  or  general.  Under  local  disturbances  are  oedema,  con- 
gestion, hemorrhage  and  inflammation.  Under  general  disturb- 
ances are  syphilis,  scurvy,  gout,  rheumatism  and  tuberculosis. 
4.  Disturbance  of  innervation,  associated  with  diseases  of  the 
spinal  cord,  as  bed-sores,  etc.  We  find  ulcer  in  the  stump  due  to 
innervation. 

Causes  of  ulcers  on  the  leg  are  due  to  traumatism,  syphilis, 
or  varicose  veins.  Traumatic  and  varicose  ulcers  are  situated  in 
the  lower  third,  and  syphilitic  ulcers  are  situated  in  the  upper 
third  of  the  leg,  as  a  rule  (  Bryant  and  Dennis). 


586  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Description  of  an  Ulcer. — The  base  may  be  shallow  or  deep; 
the  margin  may  be  everted,  undermined,  or  indurated;  the  dis- 
charge may  be  muco-purulent  or  bloody. 

Treatment. — 1.  Relieve  the  congestion.  The  best  way  is  to 
take  a  sharp  knife  and  cut  the  indurated  edge.  2.  Encourage 
healthy  granulations  by  an  antiseptic  poultice.  3.  Elevate  the 
limb  and  so  encourage  the  circulation.  We  cannot  cure  an  ulcer 
without  rest.  Stimulate  granulations  by  balsam  of  Peru,  aro- 
matic wine,  cinchona  bark,  iodoform,  bismuth,  or  oxide  of  zinc. 
Inquire  into  the  constitution  of  the  patient.  If  he  has  syphilis, 
gout  or  tuberculosis,  you  must  treat  these  diseases.  If  the  pa- 
tient suffers  from  varicose  ulcers  support  the  blood-vessels  per- 
manently by  elastic  stockings,  if  it  returns  ligate  the  veins  twenty 
to  forty  times. 

Skin-grafts  may  be  used.  Take  the  skin  from  the  thigh  and 
plant  it  over  the  ulcer  (Bryant  and  Dennis). 

UREMIA. 

By  uraemia  is  understood  the  accumulation  in  the  blood  of 
exerenientitious  substances  of  the  urine. 

Causes. — The  primary  cause  is  a  failure  of  the  kidneys  to 
perform  their  normal  function  of  elimination,  and  the  consequent 
accumulation  in  the  circulation  of  some  or  all  of  the  poisonous 
elements  of  the  urine.  This  condition  may  occur  in  the  course 
of  any  disease  in  which  suppression  of  the  renal  secretion  takes 
place ;  but  it  is  more  frequent  in  acute  Bright's  disease 
(Loomis). 

Symptoms. — Acute  uraemia  is  usually  preceded  by  certain 
signs,  such  as  oedema  in  various  parts  of  the  body,  restlessness, 
or  an  almost  irresistible  desire  to  sleep,  vertigo,  headache,  deli- 
rium, nausea,  vomiting,  diarrhoea  and  impaired  vision.  The 
countenance  has  a  pale,  waxy  or  dingy  appearance,  and  the  urine 
is  scanty,  high-colored,  bloody,  albuminous,  and  contains  casts. 
The  convulsions  may  consist  of  a  single  paroxysm,  and  may  simu- 
late epilepsy.  There  is  a  strong  urinous  odor  emanating  from  the 
perspiration.     The  temperature  may  be  as  high  as  107°  F. 

Urcemic  coma  may  come  on  gradually  or  suddenly.  The 
patient  may  be  easily  aroused.      Urcemic  coma  is    always  accom- 


URiEMIA URTICARIA.  587 

paiiied  by  stertor.  The  stertor  is  peculiar;  it  is  not  the  "  snor- 
ing "  of  apoplexy,  but  a  sharp,  hissing  sound.  The  respirations 
are  at  first  accelerated  but  they  soon  become  slow  and  labored. 
After  a  time  the  temperature  falls  below  the  normal  standard; 
the  face  is  pale  (Loomis). 

Differential  Diagnosis. — Uraemia  may  be  mistaken  for  epi- 
lepsy, cerebral  apoplexy,  hysterical  convulsions.  In  epilepsy 
the  temperature  is  not  elevated.  The  initial  cry  and  corpse -like 
pallor  of  the  face  in  epilepsy  are  wanting  in  uraemia.  In  cere- 
bral apoplexy  coma  always  precedes  convulsions.  In  hysterical 
convulsions  the  patient  falls  with  a  scream  into  a  convulsive  con- 
dition and  afterwards  passes  a  large  quantity  of  pale  urine 
(Loomis). 

Prognosis. — Will  depend  upon  the  amount  of  the  poison  in 
the  system. 

Treatment. — Diaphoresis,  by  the  hot-air  baths  and  by  the 
use  of  pilocarpin  is  of  service.  Digitalis  acts  efficiently — is 
diuretic  without  stimulating  the  kidneys.  It  increases  the  power 
of  the  heart's  action.  The  diminished  secretion  of  urine  is  due 
to  obstruction  in  the  capillary  circulation  of  the  kidneys.  Digi- 
talis, by  increasing  the  heart  power,  overcomes  such  obstruction. 
Chloroform  is  not  a  good  remedy  in  uraemia.  Loomis  believes 
morphine  administered  hypodermically  to  be  the  most  efficient 
remedy  for  the  treatment  of  uraemia.  It  arrests  muscular  spasm. 
It  establishes  profuse  diaphoresis.  It  facilitates  the  action  of 
cathartics  and  diuretics.  Dry  and  wet  cupping  over  the  loins 
aid  in  establishing  the  renal  function  (Loomis). 

URTICARIA. 

Called  also  hives  and  nettle-rash,  is  an  ephemeral  eruption 
of  the  skin,  with  wheals  and  itching,  from  malassimilation,  etc. 

Causes. — The  cause  may  be  neurotic.  The  vaso- motor  nerves 
are  principally  at  fault.  This  vaso-motor  nerve  disturbance  may 
result  from  direct  irritation  of  the  skin,  or  may  be  reflex,  arising 
from  the  irritation  of  distant  organs  and  tissues.  The  sting  of 
the  common  nettle  is  the  most  familiar  instance  of  local  irrita- 
tion.    It  is  often  called  forth,  in  those  who  are  predisposed,   by 


588  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

scratching  the  skin,  or  by  the  bite  or  sting  of  insects,  such  as  the 
flea,  the  bug,  the  mosquito  and  the  wasp.  The  washing  of  the 
face  with  warm  water  often  brings  out  hives.  The  internal 
causes  which  may  produce  nettle-rash  by  reflex  action  are:  irrita- 
tion of  the  uterine  nerves;  in  some  persons  mental  emotion;  in- 
digestion, certain  kinds  of  food,  such  as  oysters,  crabs  and  lob- 
sters, nuts,  onions,  pork,  sausages,  and  medicines,  such  as  valerian, 
copaiba,  cubebs,  turpentine  and  quinine  (Anderson). 

Symptoms. — The  rash  is  familiar  to  all.  The  centre  of  each 
wheal  is  pale,  while  the  periphery  is  red.  The  rash  comes  out 
with  great  rapidity,  and  may  disappear  in  a  few  hours 
(Anderson). 

Treatment. — Discover  and  remove  the  cause  or  causes.  A 
sharp  purge  is  of  use.  Atropia  and  bromide  of  potassium  are 
sometimes  useful.  Locally  the  parts  may  be  sponged  with  vine- 
gar and  water,  or  with  a  lotion  of  carbolic  acid  (Anderson). 

VAGINISMUS. 

Called  also  vulvismus,  is  a  spasmodic  contraction  of  the 
muscles  of  the  pelvic  floor — not  of  the  sphincter  vaginas  muscle 
alone.  It  is  seen  alike  in  single  and  in  married  women,  and  is 
caused  by  violence  in  sexual  intercourse,  as  when,  in  a  newly 
married  couple,  there  is  some  difficulty  of  entering  the  vagina, 
and  repeated  attempts  set  up  an  irritation  resulting  in  reflex 
contraction  whenever  the  penis  strikes  the  anterior  margin  of 
the  peringeuru.  It  is  sometimes  seen  after  child-birth  caused  by 
injury  to  the  pelvic  floor.  It  may  be  caused  by  local  disease  of 
the  parts,  or  it  may  be  due  to  some  disease  of  the  spinal  cord. 
The  spasm  of  the  muscles  is  usually  accompanied  by  pain,  often 
severe,  and  rendering  the  accomplishment  of  the  sexual  act  not 
only  difficult,  but  impossible  (Morris). 

Varieties. —  Vaginismus  inferior r where  the  muscles  of  the 
pelvic  outlet  alone  are  involved,  and  vaginismus  superior,  where 
the  levator  ani  muscle  participates  in  the  contraction;  the  last  is 
a  rare  affection,  and  particularly  that  form  where  the  latter 
muscle  only  is  at  fault.  This  variety  sometimes  comes  on  at  the 
end  of  the  sexual  act,  and  the  penis  may  be  grasped  by  its  con- 
traction and  retained  in  the  vagina  for  some  time. 


vulvitis.  589 

Treatment. — Discover  and  remove  the  cause.  If  an  irritable 
hymen  is  the  cause  of  the  trouble,  the  patient  should  be  ether- 
ized and  the  hymen  dissected  out.  If  no  inflammation  is  present 
gradual  dilatation  of  the  vagina  does  good. 

VULVITIS. 

Is  an  inflammation  of  the  vulva.  It  may  be  either  ca- 
tarrhal, follicular,  diabetic  or  aphthous. 

Cause. — /.  Of  Catarrhal  Vulvitis. — Want  of  cleanliness; 
gonorrhoea,  exposure  to  cold;  extension  of  inflammation  from 
other  parts;  masturbation. 

Symptoms. — Those  of  an  ordinary  catarrhal  inflammation, 
viz:  swelling,  redness,  heat,  pain  and  dryness  of  the  parts,  fol- 
lowed by  increased  discharge. 

Treatment. — The  parts  must  be  kept  perfectly  clean  and 
warm  hip-baths  should  be  freely  employed.  Dusting  with  bis- 
muth subnitrate  and  borated  cotton  between  the  labia  are  of 
service.     If  the  disease  be  of  specific  origin  (see  vaginitis). 

II  Follicular  vulvitis  is  that  form  in  which  the  sebaceous 
follicles  are  involved. 

Treatment. — The  best  treatment  consists  in  warm  sedative 
applications,  warm  baths,  and  alkaline  washes. 

III  Diabetic  Vulvitis. — Is  dependent  upon  the  presence 
of  a  fungus  developed  from  the  sugar  in  the  urine,  and  spreading 
from  the  orifice  of  the  urethra  to  the  vulva.  The  parts  become 
dry  and  hard  and  of  an  intensely  red  color.  The  affection  is 
attended  with  intense  and  very  troublesome  itching. 

Treatment. — The  general  condition  of  the  system  must  be 
treated  as  well  as  the  local  (Morris). 

IV.  Aphthous  Vulvitis. — Is  a  disease  of  childhood  follow- 
ing the  exanthemata,  or  any  debilitated  condition  of  the  system. 

Treatment. — Constitutional  remedies  are  as  important  as 
local  means.  Cod-liver  oil,  quinine,  and  iron  should  be  given 
and  the  most  scrupulous  local  cleanliness  insured  (Morris). 


,590  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

VARICOSE  VEINS. 

Are  an  enlarged  and  tortuous  state  of  the  veins,  which  are 
usually  thickened,  rigid,  and  formed  into  irregular  pouches. 

Situation. — They  are  most  frequently  seated  on  the  lower 
extremities,  scrotum  and  rectum.  Varicose  veins  of  the  leg  are 
accompanied  by  pain,  weight,  and  fatigue  on  taking  exercise; 
they  cause  ulcers  and  excoriations  of  the  skin;  they  sometimes 
burst,  causing  profuse  hemorrhage,  and  occasionally  blood  clots 
in  the  veins,  which  may  terminate  in  an  abscess. 

Treatment. — The  palliative  treatment  consists  in  applying 
strips  of  leather  over  the  part  or  a  common  roller  or  an  elastic 
stocking,  which  should  be  applied  in  the  morning  before  the 
patient  rises.     For  the    radical    cure  many   methods  have  been 

devised  (Morris). 

VARICOCELE. 

Is  a  varicose  state  of  the  veins  of  the  spermatic  cord.  It  is 
more  common  on  the  left  side. 

Treatment. — Keep  the  bowels  open;  wash  the  scrotum  fre- 
quently with  cold  water;  support  the  scrotum  with  a  suspensory 
bandage.  For  the  radical  cure,  it  is  recommended  to  pass  a 
ligature  subcutaneously.  Operations  on  the  veins  are  always 
attended  with  some  risk.  Many  surgeons  cut  down  on  the  veins 
andligate  them  with  cat-gut  (Morris). 

VERTIGO. 

Has  been  well  denned  as  the  consciousness  of  disordered 
equilibration.  It  is  not  properly  a  substantive  disease,  but  may 
be  the  only  symptom  of  the  morbid  state  to  which  it  is  referable. 
It  is  a  subjective  state,  in  which  the  individual  affected,  or  the 
objects  about  him,  seem  to  be  in  raj3id  motion,  of  a  rotary,  circu- 
lar, or  to-and-fro  kind.  In  common  language  vertigo  is  known 
as  dizziness.  It  may  be  momentary  or  of  long  duration  (Bar- 
tholow  and  Loomis). 

Causes. — Vertigo  is  a  purely  functional  affection.  It  has 
been  divided  into  ocular,  aural,  stomachic,  nervous,  epileptic, 
cardiac,  cerebral  and  gout//. 


VERTIGO.  591 

I.     Paralysis  of  a  single  muscle  may  cause  ocular  vertigo. 

II  Aural  vertigo  is  named  after  its  discoverer — Meniere's 
disease,  and  may  be  caused  by  disease  of  the  semicircular  canals, 
or  other  ear  troubles. 

III.  Gastric  vertigo  is  the  most  common,  and  is  an  almost 
invariable  attendant  on  dyspepsia  and  hepatic  disorder. 

IV.  Nervous  vertigo  is  induced  by  physical  or  nervous 
excesses,  and  Ramskill  ranks  vertigo  from  overwork  as  next  to 
gastric  in  frequency.  It  is  also  caused  by  excessive  use  of  tea, 
coffee,  tobacco  and  alcohol. 

V.  Epileptic  vertigo  precedes  an  epileptic  seizure. 

VI  Cardiac  vertigo  is  a  condition  of  ana3mia  of  the  brain 
and  is  closely  allied  to  fainting.  The  subjects  of  cardiac  vertigo 
have  a  swimming  sensation  in  the  head,  darkness  falls  on  the 
eyes  and  they  become  chilly  and  weak.  It  is  associated  with 
fatty  heart  and  dilatation  of  the  right  cavities. 

VII  Cerebral  vertigo  occurs  as  a  symptom  in  cerebral 
anaemia  and  cerebral  congestion;  in  meningitis,  in  tumor  of  the 
brain;  in  abscess  of  the  brain;  in  cerebral  hemorrhage;  in  scler- 
osis of  the  brain;  in  chorea,  hypochondriasis  and  chronic  alco- 
holism. 

VIII  Gouty  vertigo  is  due  to  the  blood  changes  which 
characterize  the  gouty  diathesis.  The  vertigo  of  the  aged  is  a 
result  of  disordered  cerebral  circulation  produced  by  the  senile 
condition  of  the  heart  and  vessels.  Chronic  malarial  infection 
may  induce  vertigo  (Bartholow  and  Loomis). 

Symptoms. — The  sensation  may  be  that  of  objects  moving 
around  the  patient,  or  of  the  patient  moving  around  objects 
which  remain  stationary.  There  is  no  loss  of  consciousness. 
Nausea,  vomiting,  and  ringing  in  the  ears  are  frequent.  The 
first  symptom  in  ocular  vertigo  will  be  the  running  together  of 
the  letters  on  the  page,  headache,  nausea,  and  pains  in  the  eyes. 
In  Meniere's  disease,  tinnitus  aurium  accompanies  the  vertigo. 
After  the  attack  of  vertigo  passes  off  deafness  remains.  Gastric 
vertigo  is  accompanied  by  dyspeptic  symptoms,  nausea,  pyrosis, 
heartburn,  flatulence,  diarrhoea,  or  constipation.  The  mental 
state    is    often    deplorable,    and    true    melancholia    may    ensue. 


592  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Nervous  vertigo  is   apt  to   occur   after   excessive   mental   effort 
(Loomis). 

Treatment. — Gastric  vertigo  demands  the  treatment  given 
under  the  head  of  dyspepsia.  In  ocular  vertigo,  rest  for  the  eyes 
and  proper  glasses  will  remove  it.  In  aural  vertigo,  full  doses 
of  bromide  of  potassium  are  of  service.  In  nervous  vertigo,  iron, 
quinine,  strychnine,  and  the  removal  of  the  cause  are  sufficient. 
The  vertigo  of  old  age  is  benefitted  by  the  bichloride  of  mercury 
and  tincture  of  iron,  with  small  doses  of  Burgundy  wine  (Loomis.) 

VOMITING. 

Is  not  a  disease  but  a  symptom  in  a  large  number  of  dis- 
eases.    As  a  symptom  it  often  demands  treatment. 

Treatment. — Tablespoonful  doses  of  iced  champacjne  every 
fifteen  minutes  will  sometimes  arrest  the  vomiting  of  pregnancy, 
of  sea- sickness,  of  cholera,  yellow  fever,  etc.  A  little  chloroform 
(2Ttij.-ZUv.)  dropped  on  sugar  and  swallowed,  will  remove  some 
kinds  of  nausea  and  vomiting. 

The  bromides  are  serviceable  in  cerebral  vomiting,  and  in 
cholera  infantum  in  children,  and  in  some  cases  of  reflex  vom- 
iting. 

Chloral  is  highly  useful  in  vomiting  of  sea- sickness,  cholera, 
and  reflex  vomiting. 

A  minim  of  wine  of  ipecac,  given  every  half  hour  or  hour 
in  a  little  water,  will  sometimes  relieve  the  vomiting  of  preg- 
nancy, vomiting  of  drunkards,  of  migraine,  etc. 

Drop  doses  of  Foivler^s  solution,  given  before  meals,  will 
stop  vomiting  of  irritative  dyspepsia,  of  pregnancy,  of  chronic 
gastric  catarrh,  etc. 

Hydrocyanic  acid  can  be  prescribed  in  the  vomiting  of  acute 
stomach  troubles. 

Pepsin,  milk  and  lime-water,  and  bismuth  are  proper  in  the 
vomiting  of  indigestion,  of  stomach  inflammation,  of  acidity  and 
of  acute  intestinal  disorders. 

Calomel  in  very  minute  doses,  every  half  hour  or  hour,  will 
stop  some  kinds  of  vomiting. 


VARICELLA.  593 

Cerium  oxalate,  mix  vomica  and  carbolic  will  in  certain 
cases  control  vomiting.  Coniiter-irritation  at  epigastrium  often 
allays  vomiting  (Ringer  and  Bartholow). 

VARICELLA. 

Known  in  common  language  as  chicken-pox  or  swine-pox,  is 
a  febrile  affection,  characterized  by  the  appearance  of  a  vesicular 
eruption  with  the  first  elevation  of  temperature,  the  vesicles 
drying  up  and  falling  off  in  from  three  to  five  days.  It  has  been 
called  spurious  variola.  Varicella  is  the  shortest  and  mildest  of 
the  eruptive  fevers  (Bartholow  and  Smith). 

Causes. — It  is  due  to  a  specific  poison.  It  is  highly  contag- 
ious, so  that  few  children  escape  who  are  exposed  to  it.  It  is  a 
disease  of  childhood.  It  occurs  sporadically  and  epidemically. 
It  attacks  the  same  individual  but  once.  Inoculation  has  given 
negative  results.  The  period  of  incubation  varies  from  eight  to 
seventeen  days  (Bartholow,  Loomis  and  Smith). 

Symptoms. — Twenty -four  hours  preceding  the  eruption 
there  is  usually  lassitude  and  a  feeling  of  malaise.  The  eruption 
generally  appears  first  on  the  body  then  on  the  head.  About  the 
second  day  vesicles  may  appear  upon  the  tongue,  lips  and  palate. 
The  vesicles  appear  in  crops.  They  vary  in  size  from  a  pin's 
head  to  that  of  a  pea,  or  even  larger,  and  contain  a  clear  watery 
and  sometimes  yellowish  fluid.  The  number  of  vesicles  vary 
from  ten  to  a  thousand.  The  duration  of  the  disease  is  eight  or 
ten  days  (Bortholow,  Loomis  and  Smith). 

Differential  Diagnosis. — Varicella  may  be  mistaken  for  vario- 
loid. The  stage  of  invasion  of  varioloid  is  longer  than  the  stage 
of  varicella.  The  mildness  of  the  symptoms  in  varicella  is  diag- 
nostic. The  vesicular  character  of  the  eruption  from  the  start  is 
characteristic  of  varicella.  In  varioloid  the  vesicles  are  preceded 
by  papules.  In  varioloid  the  eruption  appears  first  on  the  face, 
in  varicella  it  appears  first  on  the  body.  The  umbilicated  ap- 
pearance of  the  vesicles  is  wanting  in  varicella  (Flint). 

Treatment. — Varicella  claims  no  treatment.  Rest  in  bed, 
cleanliness,  and  a  non- stimulating  diet  are  important. 


594  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

VARIOLA. 

Is  an  eruptive  disease  characterized  by  the  presence  of  pus- 
tules which  make  their  appearance  at  the  end  of  the  third 
exacerbation  of  the  initial  fever,  when  the  temperature  declines, 
but  this  apyrexia  is  followed  by  a  secondary  fever,  or  fever  of 
maturation.  It  is  known  in  common  language  as  small-pox 
(Bartholow). 

Morbid  Anatomy. — The  characteristic  lesion  of  small -pox  is 
the  eruption.  The  successive  stages  of  the  eruption  are  the 
macule,  the  papule,  the  vesicle  and  the  pustule.  The  pustule 
undergoes  desiccation.  The  macule  is  a  reddish,  slightly -elevated 
spot  due  to  congestion  of  a  circumscribed  portion  of  the  skin. 
A  characteristic  appearance  of  the  small-pox  vesicle  is  produced 
by  a  central  depression  in  its  roof,  the  so-called  umbilication  of 
the  vesicle  (Flint). 

Causes. — Small -pox  is  spread  by  a  peculiar  virus  whose 
nature  is  unknown.  In  the  open  air  the  distance  of  contagion  is 
about  two  and  one-half  feet.  Rarely  does  an  individual  have  a 
second  attack.  The  period  of  incubation  varies  from  five  to 
thirty  days,  average  fourteen  days.  The  negro  and  Indian  races 
are  particularly  susceptible  to  the  disease  (Bartholow,  Flint  and 
Loomis). 

Symptoms. — Stage  of  Invasion. — The  disease  is  ushered  in 
by  a  chill  in  the  great  majority  of  cases,  and  the  chill  is  usually 
more  marked  than  in  the  other  eruptive  fevers.  Fever  follows 
the  chill.  It  is  known  as  the  primary  fever.  It  is  often  intense, 
104°  or  105°  F.  There  are  nausea,  vomiting,  coated  tongue,  pain 
in  the  stomach,  also  in  the  limbs  andloins,  headache  and  delirium. 
The  duration  of  this  stage,  as  a  rule,  is  two  days.  The  eruption 
begins  to  appear  on  the  third  or  fourth  day. 

Stage  of  Eruption. — The  eruption,  as  a  rule,  appears  first 
on  the  face,  about  the  lips  and  chin,  then  on  the  neck  and  wrists; 
next  on  the  chest  and  arms;  then  over  the  body.  At  first  the 
eruption  appears  in  the  form  of  small  red  spots  or  specks.  It  is 
now  a  maculated  eruption.  The  central  part  of  the  maculae  be- 
comes hard,  elevated  and  pointed.  It  is  now  a  papular  erup- 
tion.    The  papulae  feel  like  small  shot  under  the  skin.     Next  a 


VARIOLOID.  595 

clear  liquid  becomes  visible  in  the  papulae,  which  now  become 
vesifiulce.  On  the  fifth  day  of  the  stage  of  the  eruption  the  vesi- 
cles are  one-quarter  to  one-third  of  an  iuch  in  diameter.  More 
or  less  of  the  vesicles  present  a  depression  in  the  centre.  They 
are  said  to  be  umbilicated.  This  appearance  is  highly  characteris- 
tic, indeed,  almost  pathognomonic.  After  this  the  vesicles  be- 
come pustules.  In  other  words  suppuration  takes  place.  On 
the  appearance  of  the  eruption  the  primary  fever  falls  almost  to 
the  normal.     This  is  a  highly  diagnostic  feature  of  small-pox. 

Stage  of  Suppuration. — Usually  on  the  sixth  day  after  the 
first  appearance  of  the  eruption,  there  is  a  recurrence  of  the  fever 
called  suppurative  or  secondary  fever.  The  face,  hands  and  feet 
swell.     The  duration  of  this  stage  is  four  or  five  days. 

Stage  of  Desiccation.— -This  stage  begins  on  about  the 
twelfth  day  of  the  disease.  The  pus  collects  into  a  thick  scab. 
During  this  stage  the  skin  exhales  a  sickening  characteristic 
odor.  The  whole  duration  of  small -pox  is  between  seventeen 
and  twenty-four  days  (Flint  and  Loomis). 

Prognosis. — Varies — from  ten  to  twenty-five  per  cent.  die. 

Treatment. — There  is  no  special  plan  of  treatment.  The  dis- 
ease will  run  its  course  and  hence  the  expectant  plan  is  to  be 
pursued  (Flint). 

VARIOLOID. 

Is  modified  small -pox.  Small -pox  is  modified  as  a  rule 
when  produced  by  inoculation.  Inoculation  had  been  practiced 
from  time  immemorial  in  China  and  Persia.  The  eruption  in 
cases  of  inoculated  small -pox  is  usually  slight.  The  pocks  rarely 
exceed  one  hundred.     Many  of  them  abort. 

As  a  rule,  variolation  or  inoculation  affords  complete  pro- 
tection ever  thereafter  against  small-pox.  It  was  a  great  bless- 
ing prior  to  the  discovery  of  vaccination.  At  the  present  day  in 
most  cases  of  varioloid  the  modification  is  due  to  vaccination. 

Vaccination  does  not  always  afford  complete  protection 
against  small -pox,  but  in  general  the  disease  is  materially  modi- 
fied. 

The  treatment  of  varioloid  is  the  same  as  ordinary  small-pox 
(Flint). 


596  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

VACCINIA,  OR  COWPOX. 

Vaccinia  and  cowpox  are  names  of  a  disease  of  the  cow 
which,  communicated  to  man,  destroys  in  the  great  majority  of 
cases  for  a  certain  period  the  susceptibility  to  small-pox.  Cow- 
pox  is  transferred  to  man  by  the  introduction  of  a  virus.  The 
operation  for  its  communication  is  called  vaccination.  For  the 
employment  of  vaccination  as  a  means  of  preventing  small-pox 
the  world  is  indebted  to  the  immortal  Jenner,  who  published  his 
discovery  in  1798.  The  history  of  vaccinia  in  man  is  as  follows: 
On  the  third  day  after  vaccination  red  points  or  small  papules 
are  apparent  where  the  vaccine  virus  was  inserted.  On  the 
fourth  day  the  papules  are  more  developed.  On  the  fifth  day 
vesicles  appear,  and  on  the  eighth  day  they  are  fully  developed. 
On  the  ninth  or  tenth  day  the  contents  of  the  vesicles  become 
purulent,  or  pustules  are  formed.  The  pustules  desiccate  and 
fall  off  about  the  twenty-fifth  day  from  the  date  of  vaccination. 
Cowpox  is  not  identical  with  small-pox,  although  allied  to  it. 
In  a  large  majority  of  cases  vaccination  affords,  for  a  time  at 
least,  absolute  protection  against  small -pox.  In  a  minority  of 
cases  the  susceptibility  to  small -pox  is  not  destroyed,  but  the 
disease  is  materially  modified,  constituting  what  is  called  vario- 
loid. Revaccinating  every  five  years  is  to  be  advocated.  The 
bovine  virus  should  be  used.  The  dangers  following  some  cases 
of  vaccination  are  abscesses,  erysipelas,  and  blood-poisoning 
(Flint). 

VALVULAR  DISEASES. 

Include  those  alterations  in  the  structure  of  the  valves  them- 
selves or  of  the  orfices  which  render  the  former  incapable  of  per- 
forming their  office  in  the  closure  of  the  latter.  The  lesions  may 
be  of  two  kinds — obstructive  or  regurgitant;  that  is,  the  orifice 
may  be  so  narrowed  as  to  obstruct  the  passage  of  the  blood,  or 
the  valves  may  be  so  damaged  as  to  permit  the  blood  to  regurgi- 
tate. The  narrowing  of  an  orifice  is  termed  stenosis;  the  incom- 
petence of  a  value  to  close  the  orifice  is  termed  insufficiency. 
There  are  four  points  at  which  these  lesions  may  occur,  viz: 
mitral,  aortic,  tricuspid,  and  pulmonic  orifices  (Bartholow). 


VALVULAR    DISEASES.  597 

Cardiac  Murmurs. — A  cardiac  murmur  is  an  abnormal  sound 
produced  within  the  heart  or  blood-  vessels,  either  by  obstruction 
to  the  blood-current,  an  abnormal  direction  of  the  blood-current, 
or  a  change  in  the  blood  constituents.  Should  any  obstruction 
exist  at  either  of  the  auricula- ventricular  orifices,  the  blood  while 
passing  through  the  opening  at  the  end  of  a  cardiac  diastole, 
will  impinge  on  such  obstruction  and  cause  a  presystolic  murmur. 

During  a  cardiac  systole,  if  the  semilunar  valves  obstruct 
the  outgoing  current,  or  if  the  mitral  or  tricuspid  valves  do  not 
wholly  close  the  auriculo  ventricular  orifices,  then,  in  the  one 
case,  the  blood-current  as  it  passes  over  the  obstruction  at  the 
semi-lunar  orifices,  will  produce  a  systolic  murmur,  and  in  the 
other  a  systolic  murmur  will  be  produced  by  the  backward 
current  through  the  abnormal  opening  at  the  auriculo -ventricular 
orifices.  If  the  pulmonary  and  aortic  system  have  back  of  them 
a  semilunar  valve  that  does  not  completely  close  that  end  of  the 
circuit,  the  blood  will  regurgitate  into  the  ventricles  during  the 
period  of  cardiac  rest,  so  that  semilunar  incompetence  causes  a 
diastolic  murmur. 

The  following  is  the  order  of  relative  frequency  of  cardiac 
murmurs:  (1)  Mitral  regurgitation;  (2)  aortic  obstruction; 
(3)  aortic  regurgitation;  (4)  mitral  obstruction;  (5)  tricuspid 
regurgitation;  (6)  trici^id  obstruction;  (7)  pulmonary  ob- 
struction;  (8)  pulmonary  regurgitation. 

Of  the  eight  cardiac  murmurs,  four  are  systolic,  two  dias- 
tolic and  two  presystolic. 

After  determining  whether  the  cardiac  murmur  be  systolic, 
diastolic  or  presystolic,  we  next  find  the  point  of  its  maximum 
intensity.  Murmurs  arising  at  the  mitral  valve  are  loudest  at 
the  apex  of  the  heart,  or  just  above  it;  tricuspid  murmurs  are 
loudest  over  the  lower  part  of  the  sternum;  pulmonary  murmurs, 
in  the  second  left  intercostal  space  close  to  the  sternum,  and 
aortic  murmurs  in  the  second  right  intercostal  space  at  the  edo-e 
of  the  sternum  (Looniis). 

Rational  Signs  and  Symptoms  of  Valvular  Defects. — When 
stenosis  exists  at  an  orifice,  the  amount  of  blood  passing  through 
is  necessarily  lessened,  with  the  effect  to  cause  ischsemia  and 
lowered  tension  in  front,  and  stasis  and  abnormally  high  tension 


598  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

behind.  The  same  result  follows  if  the  contractions  are  feeble 
and  the  cavity  dilated.  Lesions  of  the  aortic  orifice,  either  ob- 
structive or  regurgitant,  lead  to  dilatation  of  the  left  ventricle,  to 
diminished  blood- supply,  and  lowered  tension  in  the  vessels  of 
the  aortic  system,  and  to  increased  pressure  and  distention  in  the 
left  auricle  and  pulmonary  veins.  Mitral  lesions,  either  obstruc- 
tive or  regurgitant,  cause  abnormal  fullness  and  distention  of  the 
left  auricle  and  pulmonary  system,  and  ischaeniia  and  lowered 
tension  in  the  left  ventricle  and  aortic  system.  Lesions  of  the 
tricuspid  orifice  induce  dilatation  of  the  right  auricle  and  in- 
creased pressure  in  the  venae  cava?,  and  ischaemia  and  lowered 
pressure  in  the  right  ventricle  and  pulmonary  artery. 

Lesions  of  the  pulmonary  orifice  bring  about  dilatation  of 
the  right  ventricle  and  elevated  tension  in  the  right  auricle  and 
venae  cavae,  and  ischaemia  and  lowered  tension  in  the  pulmonary 
artery.  All  valvular  lesions  bring  about,  sooner  or  later,  a  state 
of  the  circulatory  organs  in  which  there  are  ischaemiaand  lowered 
tension  in  the  aortic  system  and  stasis  and  high  tension  in  the 
venous  system. 

When  condensation  takes  place  this  is  not  the  case.  Stenosis, 
of  an  outlet  is  compensated  by  dilatation  of  the  cavity  and  hyper- 
trophy of  the  walls.  But  the  compensation  may  be  easily  over- 
come, and  symptoms  of  valvular  disease  ensue.  The  most  usual 
pulmonary  disturbance  induced  by  valvular  disease  is  stasis  of 
the  blood,  which  leads  to  catarrh  of  the  bronchi,  and  is  accom- 
panied by  cough,  mucous  expectoration,  mucous  and  sub-mucous 
rales,  etc.  There  is  difficulty  of  breathing.  There  may  be 
cyanosis  with  pain  in  the  chest,  shoulder,  and  down  the  arm. 
The  condition  of  over-fullness  of  the  venous  is  seen  in  the  dis- 
tended state  of  the  superficial  veins  (Bartholow). 

AORTIC  OBSTRUCTION,  OR  STENOSIS, 

This  is  a  common  cardiac  lesion,  and  is  always  accompanied 
by  more  or  less  hypertrophy  of  the  left  ventricle  (Loomis). 

Causes. — Aortic  stenosis  is  most  frequently  met  in  middle 
and  advanced  life;  the  mean  age  being  forty- seven  years.  Inter- 
stitial endocarditis  of  rheumatic  origin  is  its  most  frequent  cause. 


VALVULAR    DISEASES.  599 

Chorea  and  chronic  Blight's  disease  may  cause  it.  Atheroma  or 
arteritis  deformans  extending  to  the  valves  somestimes  gives  rise 
to  it.  Men  suffer  from  aortic  stenosis  oftener  than  women. 
Occupations  that  involve  repeated,  sudden  and  sever  muscular 
effort  induce  it  (Loomis). 

Symptoms. — The  subjective  symptoms  of  aortic  stenosis  are 
rarely  well  marked.  When  the  compensation  is  overcome, 
then  the  pulmonary  vessels  and  the  venous  system  are  abnorm- 
ally full.  The  scanty  arterial  supply  causes  pallor  of  the  face, 
and  syncope  may  occur  from  cerebral  anaemia,  but  these  are  late 
symptoms.  The  pulse  is  normal  in  frequency,  diminished  in 
volume  and  fullness,  and  as  a  rule  regular.  Signs  of  arterial 
anaemia  usually  precede  those  of  venous  engorgement.  There 
may  be  slight  palpitation  and  paroxysmal  pain  in  the  chest. 
Aortic  stenosis  is  more  often  associated  with  cerebral  embolism 
than  any  other  valular  lesion.  The  left  middle  cerebral  artery  is 
the  most  common  seat  of  cardiac  emboli  (Loomis). 

Physical  Signs. — Inspection  shows  the  area  of  cardiac  im- 
pulse to  be  abnormally  increased. 

Palpation. — The  impulse  is  felt  to  be  forcible,  and  may  be 
accompanied  by  a  heaving  or  lifting  sensation.  The  apex  is  dis- 
placed to  the  left  and  slightly  downward. 

Percussion. — The  area  of  cardiac  dullness  increases. 

Auscultation. — Aortic  obstructive  murmurs  are  loudest  and 
most  distinct  at  the  second  right  intercostal  space  and  at  the 
sternal  insertion  of  the  third  left  costal  cartilage.  They  are  sys- 
tolic and  accompany  the  first  sound  of  the  heart.  These 
murmurs  are  always  harsh,  and  heard  most  distinctly  at  the 
commencement  of  the  systole.  The  area  of  diffusion  of  this 
murmur  follows  the  law  that  a  murmur  is  propagated  in  the 
direction  of  the  blood- current.  It  is  conveyed  along  the  aorta 
into  the  carotids  and  one  of  its  characteristics  is  that  it  is  heard 
in  the  great  vessels  of  the  neck.  It  maybe  heard  in  the  abdom- 
inal and  thoracic  aorta  (Loomis). 

Differential  Diagnosis.— Aortic  obstruction  may  be   mistaken 
for  mitral  and  tricuspid  regurgitation,  an  ancemic  bruit,  or  the, 
murmur  of  a   thoracic    aneurism.     Both    mitral    and    tricuspid 
regurgitation  and  aortic  stenosis  produce  a  systolic  murmur.  The 


600  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

murmur  of  aortic  stenosis  is  heard  with  its  maximum  intensity  at 
the  third  left  sterno-costal  articulation,  and  diminishes  in  inten- 
sity toward  the  apex  of  the  heart.  The  murmur  of  mitral  regur- 
gitation is  heard  loudest  at  the  apex-beat.  The  murmur  of  aortic 
stenosis  is  conveyed  into  the  vessels  of  the  neck;  that  of  mitral 
regurgitation  to  the  left,  in  the  direction  of  the  apex-beat,  and  is 
heard  behind,  between  the  fifth  and  eighth  dorsal  vertebrae,  at 
the  left  of  the  spine,  with  very  nearly  the  same  intensity  as  at  the 
apex.  The  pulse  in  aortic  stenosis  is  normal  in  frequency,  di- 
minished in  volume  and  fulness,  and,  as  a  rule,  regular  in  rhythm; 
while  in  mitral  regurgitation  it  is  irregular  in  rhythm  and  force, 
and  is  easily  increased  in  frequency.  Gastric,  intestinal,  renal, 
hepatic,  and  bronchial  symptoms  are  present  in  mitral  regurgita- 
tion, while  the  subjective  symptoms  of  aortic  obstruction  are 
cerebral  in  character.  The  murmur  of  aortic  stenosis  is  harsh-, 
that  of  mitral  regurgitation  soft,  and  often  musical. 

Tricuspid  regurgitation  is  accompanied  by  a  systolic  mur- 
mur which  is  rarely  heard  above  the  third  rib  ;  while  that  of 
aortic  stenosis  has  its  point  of  maximum  intensity  at  the  second 
right  intercostal  space  and  at  the  sternal  insertion  of  the  third 
left  costal  cartilage.  Tricuspid  regurgitation  is  accompanied  by 
jugular  pulsation;  while  the  murmur  of  aortic  obstruction  is 
heard  in  the  arteries  of  the  neck.  The  pulse  in  tricuspid  disease 
is  normal;  in  aortic  stenosis  it  is  diminished  in  volume  and  ful- 
ness and  is  sometimes  hard  and  wiry. 

Ancemia  produces  a  murmur  heard  loudest  in  the  carotids 
and  accompanied  by  a  venous  hum.  In  ana?mia  there  are  three 
murmurs:  cardiac,  venous,  and  arterial.  The  murmur  is  soft 
and  blowing  in  anaemia,  and  harsh  in  aortic  obstruction. 

In  thoracic  aneurism  the  dilating  impulse  on  palpation,  the 
normal  force  of  the  heart-beat,  the  single  and  double  bruit,  and 
the  pain  are  all  important  signs,  which  are  absent  in  aortic  sten- 
osis (Loomis). 


VALVTLAR    DISEASES.  601 

AORTIC  INSUFFICIENCY,  OR  REGURGITATION, 

This  is  an  abnormal  condition  of  the  aortic  valves,  -which 
prevents  their  complete  closure,  and  allows  a  backward  current 
of  blood  to  flow  from  the  aorta  into  the  left  ventricle  during-  its 
diastole  (Loomis). 

Causes. — Eheumatic  endocarditis  is  the  chief  cause;  but  it 
may  follow  sudden  and  violent  muscular  effort,  atheroma  of  the 
aorta,  or  endarteritis.  Dilatation  of  the  aorta  at  its  origin  may 
induce  it.  Alcoholismus  and  gout  predispose  to  it.  Fagge  says 
only  fifty  per  cent,  of  the  cases  give  a  rheumatic  history 
(Loomis). 

Symptoms. — So  long  as  hypertrophy  compensates  for  the  re- 
gurgitation, there  is  little  or  no  inconvenience  experienced  by 
the  patient.  In  time  the  hypertrophy  induces  excessive  heart- 
action  during  excitement  or  violent  muscular  effort.  The  heart- 
action  then  becomes  labored,  and  the  patient  is  anxious,  nervous 
and  fretful,  and  knows  well  that  exercise  will  increase  his  un- 
comfortable symptoms.  The  respirations  are  accelerated  with 
the  cardiac  palpitation;  as  the  disease  advances,  attacks  of  head- 
ache and  vertigo  become  more  and  more  prolonged  and  severe; 
the  patient  complains  of  muscce  volitantes,  dyspnoea,  and  giddi- 
ness, and  is  compelled  to  sleep  with  his  head  elevated.  Palpita- 
tion and  a  visible  carotid  impulse  are  now  constantly  present.  A 
frequent  symptom  is  a  distinctly  paroxysmal  shooting  or  stab- 
bing pain  over  the  heart,  in  the  left  shoulder,  or  extending  down 
the  left  arm.  The  pain  may  pass  from  the  middle  of  the  sternum 
down  the  right  arm.  The  pain  may  be  accompanied  by  numb- 
ness. When  mitral  insufficiency  exists  with  the  aortic,  the  sys- 
temic veins  become  overloaded  and  cyanosis  and  dropsy  result; 
the  dropsy  appears  first  as  oedema  of  the  feet,  and  gradually  ex- 
tends upward  until  there  is  general  anasarca. 

Later  in  the  disease,  there  is  orthopncea,  sudden  startino-s  in 
sleep,  angina  pectoris,  and  there  may  be  albuminuria  and  en- 
largement and  tenderness  of  the  liver.  Attacks  of  syncope  occur. 
These  patients  may  die  at  any  moment.  The  pulse  is  visible  in 
the  vessels  of  the  head,  neck  and  upper  extremities.  It  is  often 
called  the  u  piston  pulse"  "  Corrigan's  pulse"  uivater -hammer" 


602  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

"jerking"  "splashing"  or  "collapsing"  pulse.  It  is  large  and 
distinct.  When  the  arm  is  raised  above  the  head,  its  character- 
istics are  more  apparent.  The  radial  impulse  is  felt  a  little  after 
the  apex-beat  (Loomis). 

Physical  Signs, — Inspection  shows  an  increase  in  the  area 
and  force  of  the  apex -beat.  When  compensation  ceases  to 
balance  the  forces  in  the  heart,  the  apex-beat  becomes  feeble  and 
diffused. 

Palpation  gives  a  heaving,  lifting  impulse  which  is  trans- 
mitted over  a  large  area.  The  apex-beat  is  displaced  down  and 
toward  the  left,  sometimes  as  far  as  the  eighth  rib,  and  two  and 
one-half  inches  to  the  left  of  the  left  nipple. 

Percussion  gives  increased  area  of  dullness. 

Auscultation. — Aortic  regurgitation  is  attended  by  a  dias- 
tolic murmur,  which  may  take  the  place  of,  or  immediately 
follow,  the  second  sound  of  the  heart.  This  murmur  has  its 
maximum  intensity  at  the  sternal  end  of  the  second  right  inter- 
costal space,  or  at  the  sternal  junction  of  the  third  rib  on  the 
left  side.  Its  area  of  diffusion  is  greater  than  any  other  cardiac 
murmur.  It  may  be  heard  in  the  carotids  and  at  the  sides  of  the 
chest.  It  is  a  soft,  blowing  murmur,  sometimes  rough  and  fre- 
quently musical  (Loomis). 

Differential  Diagnosis. — Aortic  regurgitation  may  be  mistaken 
for  aortic  stenosis,  mitral  obstruction,  aneurism  of  the  aorta,  and 
pulmonic  insufficiency.  Aortic  stenosis  gives  a  systolic  murmur, 
while  aortic  regurgitation  produces  a  diastolic  murmur.  Mitral 
obstruction  gives  a  presystolic  murmur,  while  aortic  reflux  a 
diastolic  murmur.  Mitral  stenosis  is  accompanied  by  no  hyper- 
trophy or  dilatation  of  the  left  ventricle;  whereas,  these  condi- 
tions are  always  present  in  aortic  reflux.  The  murmur  of  mitral 
stenosis  is  the  longest  of  all  cardiac  murmurs,  and  is  never 
heard  behind;  whereas,  that  of  aortic  regurgitation  is  heard  at 
the  sides  of  the  chest  and  along  the  spinal  column.  In  aneurism 
there  is  absence  of  left  ventricular  dilatation  and  hypertrophy, 
and  j>resenceof  a  peculiar  jerking  pulse.  Pulmonic  insufficiency 
is  the  rarest  of  all  valvular  lesions. 


MITRAL    OBSTRUCTION,    OR    STENOSIS.  603 

MITRAL  OBSTRUCTION,  OR  STENOSIS. 

Stenosis  of  the  mitral  orifice  probably  never  occurs  without 
some  insufficiency. 

Causes. — Mitral  stenosis  is  most  frequent  in  the  young;  it 
rarely  occurs  after  fifty.  It  is  twice  as  frequent  in  females  as  in 
males.  It  is  frequently  of  congenital  origin.  Acute  rheumatic 
endocarditis  is  its  most  frequent  cause  (Loomis). 

Symptoms. — The  subjective  symptoms  of  mitral  stenosis  are 
few.  Usually  after  violent  exercise  there  is  more  or  less  cardiac 
palpitation,  and  this  will  cease  as  soon  as  the  auricle  can  empty 
itself,  which  is  accomplished  by  the  patient  assuming  a  recum- 
bent position  on  the  right  side,  with  the  head  slightly  elevated. 
This  class  of  patients  are  usually  pale  and  anaemic,  and  frequently 
experience  a  sharp  pain  in  the  region  of  the  apex-beat.  The 
pulse  is  regular  and  normal  in  character,  so  long  as  the  auricular 
hypertrophy  compensates  for  the  auricular  dilatation.  The 
passive  pulmonary  hyperemia  which  attends  the  advanced  stages 
of  this  form  of  cardiac  disease  causes  habitual  dyspnoea,  which  is 
exaggerated  by  physical  exertion  and  by  a  dry,  hacking, 
"teasing"  cough,  which  resembles  the  so-called  nervous  cough. 
After  severe  exercise,  a  pint  of  glairy,  watery  mucus  may  be  ex- 
pectorated. The  mucus  may  be  blood-stained,  indicative  of 
pulmonary  congestion  aud  oedema.  Haemoptysis  is  not  infre- 
quent, and  small  quantities  of  pure,  florid  blood  may  be  expecto- 
rated.    Orthopncea  is  a  rare  symptom  (Loomis). 

Physical  Signs. — Inspection. — As  the  left  ventricle  does  not 
receive  its  normal  quantity  of  blood,  the  cardiac  impulse  is 
feeble. 

Palpation.— On  palpation,  the  apex-beat  is  less  forcible 
than  normal,  and  a  distinct  purring  thrill  will  be  communicated 
to  the  hand.  This  thrill  is  a  constant  attendant  of  mitral 
steno>i>. 

Percussion. — The  increased  size  of  the  left  auricle  may 
cause  an  increase  in  the  area  of  cardiac  dulness,  upward  and  to 
the  left,  at  the  second  left  intercostal  space. 

Auscultation. — Mitral  stenosis  is  eharacterized  by  a  loud 
"churning,'1   "grinding,"  or    blubbering"    presystolic    murmur. 


60-4  A    COMPENDIUM    OF    PRACTICAL     MEDICIJNTE. 

This  murmur  is  of  longer  duration  than  any  other  cardiac  mur- 
mur. The  murmur  is  heard  with  its  maximum  intensity  a  -little 
above  the  apex -beat.  It  is  louder  when  the  patient  is  erect  than 
when  in  a  recumbent  posture.  When  mitral  reflux  and  mitral 
obstruction  coexist,  the  two  murmurs  run  into  each  other,  con- 
stituting a  single  murmur.  A  mitral  obstructive  murmur  is  never 
soft  or  musical  (Loomis). 

Differential  Diagnosis. — The  diagnosis  of  mitral  stenosis  de- 
pends upon  the  existence  of  two  physical  signs,  the  "purring 
thrill"  and  aloud,  long,  blubbering  presystolic  murmur. 

MITRAL  INSUFFICIENCY,  OR  REGURGITATION. 

Regurgitation  at  the  mitral  orifice  is  due  to  a  condition  of 
the  mitral  valves  which  allows  the  blood  to  flow  back  from  the 
left  ventricle  into  the  left  auricle  (Loomis)  - 

Causes. — Mitral  regurgitation  may  occur  at  any  age;  but  it 
is  especially  liable  in  the  young  to  follow  rheumatic  endocarditis, 
which  causes  extensive  thickening,  induration  and  shortening  of 
the  mitral  valves.  It  may  be  secondary  to  aortic  lesions.  Ex- 
cessive dilatation  of  the  left  ventricle  may  cause  it.  Diseases  of 
the  columns  carneae  and  chordae  tendineae  will  also  cause  mitral 
insufficiency.  Ulcerative  endocarditis  may  also  cause  it,  either 
by  perforation  and  rupture  of  the  valves,  or  by  rupture  of  the 
chordae  tendineae  (Loomis). 

Symptoms. — During  the  early  stage,  when  the  hypertrophy 
of  the  right  ventricle  compensates  for  the  regurgitation,  there  are 
no  rational  symptoms;  but  when  the  right  ventricle  is  unable  to 
overcome  the  obstruction  to  the  pulmonary  circulation  caused  by 
regurgitant  blood  current,  there  will  be  more  or  less  dyspnoea, 
and  a  short,  hacking  cough  with  an  abundant  expectoration  of 
frothy  serum.  Sometimes  the  serum  is  blood-stained.  In  ad- 
vanced cases,  the  extremities,  face  and  lips  become  blue,  the 
result  of  the  interference  with  the  capillary  return  circulation. 
The  liver  becomes  enlarged  and  hardened.  There  will  be  ano- 
rexia, nausea  and  a  sense  of  oppression  in  the  epigastrium. 
Sometimes  the  hepatic  circulation  becomes  so  obstructed  as  to 
interfere  with  bile  secretion,  and  thus  give  the  skin  a  greenish 


MITRAL    INSUFFICIENCY    OR,    REGURGITATION.  605 

tint.  There  are  frequent  attacks  of  gastric  and  intestinal 
catarrh.  Headache,  dizziness,  vertigo  and  stupor  result  from  the 
passive  cerebral  hyperemia.  The  urine  is  diminished  in  quan- 
tity, high-colored,  and  loaded  with  lithates;  it  sometimes  con- 
tains albumen.  There  may  be  free  haemoptysis.  Another  late 
symptom  of  mitral  regurgitation  is  dropsy /  it  first  appears  in 
the  lower  extremities,  and  gradually  extends  over  the  whole 
body.  The  pulse  of  mitral  regurgitation  is,  at  first,  regular  in 
force  and  rhythm;  later  it  becomes  diminished  in  volume,  irreg- 
ular and  diminished  in  force  (Loomis  and  Bartholow). 

Physical  Signs. — Inspection. — The  area  of  the  visible  cardiac 
impulse  is  increased.  The  epigastric  pulsation  is  due  to  right 
ventricular  hypertrophy,  which  is  a  condition  always  found  with 
extensive  mitral  regurgitation.  The  jugular  veins  appear  swol- 
len, especially  when  the  patient  is  lying  down.  Palpation. — 
The  apex-beat  is  displaced  to  the  left  and  is  felt  lower  than 
normal,  Palpation  sometimes  reveals  a  systolic  thrill,  which  is 
confined  to  the  region  of  the  second  left  intercostal  space  near 
the  sternum.  Percussion. — The  area  of  dullness  is  increased. 
Auscultation. — Mitral  insufficiency  is  attended  by  a  systolic 
murmur.  It  is  usually  soft  and  blowing,  but  may  be  musical. 
This  murmur  takes  the  place  of  the  first  sound  of  the  heart,  and 
is  heard  with  its  maximum  intensity  at  the  apex-beat.  A  loud 
systolic  murmur  at  the  ap>ex,  and  not  heard  at  the  back,  is  not 
indicative  of  mitral  reflux  (Loomis). 

Differential  Diagnosis. — Mitral  regurgitation  may  be  mistaken 
for  aortic  obstruction  and  tricuspid  regurgitation.  The  diagnosis 
between  mitral  reflux  and  aortic  stenosis  has  already  been  con- 
sidered. Both  mitral  and  tricuspid  insufficiency  produce  a  sys- 
tolic murmur;  a  mitral  regurgitant  murmur  has  its  maximum 
intensity  at  the  apex,  while  the  maximum  intensity  of  a  tricuspid 
regurgitant  murmur  is  to  the  left  of  the  base  of  the  ensiform 
cartilage.  Pulmonary  symptoms  are  prominent  in  mitral  reflux 
and  absent  in  tricuspid  regurgitation  (Loomis  ). 


606  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

TRICUSPID  OBSTRUCTION,  OR  STENOSIS. 

This  lesion  is  so  rare  that  there  are  no  rules  for  its  diagnosis. 
But  its  symptoms  would  be  general  cyanosis,  swollen  jugulars, 
dilated  right  auricle,, headache,  dizziness,  vertigo,  etc. 

TRICUSPID  INSUFFICIENCY,  OR  REGURGITATION. 

This  lesion  is  usually  secondary  to  mitral  disease. 

Causes. — The  most  frequent  cause  of  tricuspid  regurgitation 
is  mitral  stenosis  and  regurgitation;  next  chronic  bronchitis,  and 
pulmonary  emphysema  (Loomis). 

Symptoms. — There  may  be  cardiac  paljntation,  dyspnoea, 
irregular  heart  action,  enlarged  liver,  dingy  skin,  obstinate  con- 
stipation and  hemorrhoids.  Venous  stasis  in  the  stomach  is 
evinced  by  dyspepsia,  nausea,  vomiting  and  hamiateniesis.  Pas- 
sive cerebral  hyperemia  is  marked  by  headache,  dizziness,  vertigo, 
and  muscse  volitantes.  Placing  the  patient  in  a  horizontal  posi- 
tion, after  the  disease  has  existed  for  some  time,  causes  the  face 
to  become  turgid  and  blue.  Jugular  and  epigastric  pulsation 
are  its  characteristic  physical  signs.  A  very  late  symptom  is 
dropsy  (Loomis). 

Physical  Signs. — Inspection. — In  extensive  tricuspid  disease, 
the  area  of  cardiac  impulse  is  increased  more  than  in  any  other 
valvular  lesion.  This  area  sometimes  extends  from  the  nipple 
to  the  ensiform  cartilage.  There  is  a  visible  impulse  in  the 
jugulars. 

Palpation. — The  apex-beat  is  indistinct.  Pulsation  occurs 
in  the  epigastrium. 

Percussion. — Shows  an  increase  in  the  area  of  cardiac  dull- 
ness. 

Auscultation. — The  murmur  is  soft,  faint  and  blowing,  and 
is  heard  with  greatest  intensity  over  the  lower  part  of  the  ster- 
num.    It  is  heard  with  the  first  sound  of  the  heart  (Loomis). 

Pulmonic  Obstruction  and  Regurgitation  are  so  rare,  clinic- 
ally, that  they  may  be  disregarded  (Loomis).  Prognosis  in 
valvular  disease. — The  prognosis  varies.  In  aortic  stenosis  life 
may  be  prolonged  many  years.  Aortic  regurgitation  is  a  graver 
form  of  disease  than  aortic  stenosis.     Mitral  stenosis  admits  of 


WARTS.  607 

no  compensation.     It  is  usually  grave.     Mitral  regurgitation  is- 
not  serious  if  compensated  (Loomis). 

Treatment  of  Valvular  Diseases. — The  treatment  can  be 
summed  up  in  rest,  diet  and  regimen.  Rest  must  be  mental  as 
well  as  physical.  Straining  is  to  be  avoided.  The  appetite, 
emotions  and  passions  must  be  under  perfect  control,  hence  a 
sedentary  country  life  is  best.  The  bowels  should  be  daily 
gently  moved.  The  body  must  be  warmly  clothed.  Prolonged 
exposure  to  cold  is  to  be  avoided.  Warm  baths  are  beneficial. 
When  the  heart  power  is  feeble,  tincture  of  digitalis  and  tinc- 
ture of  perchloride  of  iron  are  to  be  given  in  ten- drop  doses, 
three  times  a  day.  In  some  cases  arsenic  acts  well.  The  use  of 
alcohol,  strong  tea  or  coffee,  or  tobacco,  is  to  be  prohibited, 
small  doses  of  quinine  and  strychnine  are  useful.  The  dropsy 
may  be  relieved  by  pulvis  jalapw  comp.,  combined  with  calomel, 
squills,  juniper,  broom  and  cream  of  tartar,  act  as  diuretics.  For 
the  precordial  pain,  a  belladonna  plaster  and  morphine  will  give 
relief.  Strophanthus  will  be  found  valuable  in  some  cases.. 
Nitro-glycerine  may  be  employed  to  lower  arterial  tension,  and 
thus  relieve  a  laboring  heart.  Caffeine  and  spartein  sometimes 
give  relief  (Loomis). 

WARTS. 

Are  outgrowths  of  the  papillae  of  the  skin.  They  are  com- 
mon on  the  hands  and  other  parts  of  the  body  of  the  young,  and 
more  rare  in  the  adult.  When  on  the  exposed  parts  of  the  body, 
they  assume  a  horny  hardness.  Warts  are  jiat  or  pedunculated. 
They  occur  on  the  neck,  orifice  of  the  nose,  mouth,  eyes,  ears, 
and  anus,  also  on  the  prepuce  and  labia.  The  flat  warts  occas- 
ionally come  and  go  in  a  way  which  cannot  be  accounted  for. 
An  epithelial  cancer  may  appear  in  a  wart.  Venereal  warts,  so- 
called,  are  very  abundant,  whether  they  grow  from  the  glans 
penis  or  prepuce  of  the  male  or  labia  of  the  female.  They  are 
pedunculated,  moist,  and  highly  vascular,  and  are  clearly  con- 
tagious. Warts,  however,  may  occur  at  times  in  these  pa  its 
without  any  venereal  contact  (Bryant). 

Treatment. — Pare  away  the  cuticle  and  then  touch  the  sur- 
face with  a  glass  rod  moistened  with  strong  acetic  acid,  carbolic 


608  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

acid,  acid  nitrate  of  mercury,  or  potassa  fusa,  care  being  taken 
to  protect  the  skin  around  the  wart.  Pedunculated  dry  warts 
should  be  cut  off  with  the  knife  or  scissors.  The  application  of 
some  powder  as  oxide  of  zine,  or  even  starch  may  cause  them  to 
dry  up,  and  disappear  (Bryant). 

YELLOW  FEVER, 

Is  an  endemic  miasmatic  contagious  disease,  which  usually 
appears  as  an  epidemic.  It  prevails  most  in  tropical  regions, 
occurring  only  south  of  48°  north  latitude,  and  is  characterized 
by  a  yellowish  discoloration  of  the  skin.  It  has  been  called 
black-vomit  (Loomis). 

Morbid  Anatomy. — The  liver  is  usually  slightly  enlarged. 
Its  color  is  yellow,  like  butter,  cheese,  mustard,  or  chamois. 
The  blood  is  of  a  darker  color  than  normal,  and  coagulates 
slowly.  The  mucous  membrane  of  the  stomach  and  intestines  is 
the  seat  of  hemorrhagic  erosion,  which  causes  the  black-vomit. 
Changes  take  place  in  the  heart,  lungs,  kidneys,  etc.  (Loomis 
and  Flint). 

Causes. — Nothing  is  as  yet  known  of  the  nature,  form  and 
composition  of  the  morbific  principle,  or  specific  microbe  of 
yellow  fever.  It  is  indigenous  in  warm  climates.  Yellow  fever 
is  rarely  developed  south  of  20°  south  or  north  of  40°  north 
latitude.  The  miasm  is  more  active  at  night  than  in  the  day- 
time. The  natives  of  yellow-fever  localities  are  rarely  attacked. 
The  disease  is  rarely  experienced  a  second  time  in  the  same  indi- 
vidual. The  negro  race  seems  to  be  singularly  exempt  from  a 
liability  to  this  disease.  All  ages  suffer.  The  special  cause  is 
destroyed  by  cold.  It  is  a  matter  of  common  observation  that 
an  epidemic  is  arrested  by  one  or  two  hard  frosts.  Commercial 
seaports  are  pre-eminently  the  starting-points  of  great  ejndemics. 
Crowding  is  one  of  the  essentials  to  its  development.  The 
period  of  incubation  varies  in  duration  from  twelve  hours  to 
fifteen  days  (Flint  and  Loomis). 

Symptoms.— An  attack  of  yellow  fever  usually  is  abrupt.  It 
is  denoted  generally  by  a  chill,  with  or  without  rigor.  Fever 
follows,  varying  between  102°  and    110°  F.     The    pulse    seldom 


YELLOW    FEVER.  609 

exceeds  100.  The  tongue  is  coated.  Vomiting  may  occur  early 
but  is  usually  a  later  symptom.  The  bowels  as  a  rule,  are  con- 
stipated. Cephalalgia  is  sometimes  intense.  Pain  in  the  loins 
and  calves  of  the  legs  is  sometimes  a  prominent  symptom.  The 
eyes  are  reddened,  irritable,  watery,  or  tearful.  The  fever  con- 
tinues for  a  period  varying  between  a  few  hours  and  three  days. 
Then  follows  either  a  marked  abatement  or  entire  cessation  of 
fever.  The  condition  following  the  febrile  paroxysm  has  been 
called  "the  state  of  calm.'"  This  is  called  the  second  stage  of 
the  disease.  In  a  large  proportion  of  fatal  cases  and 
in  a  few  of  the  cases  ending  in  recovery  the  blach  vomit 
occurs.  This,  taken  in  connection  with  other  symp- 
toms, is  pathognomonic  of  the  disease.  The  black  vomit  rarely 
occurs  until  after  the  febrile  paroxysm,  and  usually  ceases  twelve 
to  twenty-four  hours  before  death.  During  the  second  stage  the 
evacuations  from  the  bowels  resemble  sometimes  tar  or  molasses. 
Yellowness  of  the  surface  of  the  body  occurs  after  the  febrile 
paroxysm.  Hemorrhage  from  the  stomach,  intestines,  kidneys, 
bladder,  nostrils,  gums,  uterus,  etc.,  is  often  a  striking  feature. 
Patients  sometimes  do  not  take  to  the  bed,  but  keep  about  their 
usual  avocations,  not  thinking  themselves  much  ill,  often  a  few 
hours  before  death.  The  face  is  flushed,  the  eyes  injected,  bril- 
liant, transparent,  fiery  and  glassy.  The  countenance  is  that  of 
suffering,  dejection,  anxiety,  anguish,  despair,  terror,  stupidity, 
vacancy,  astonishment,  etc.  The  duration  of  the  disease  after 
the  febrile  paroxysm  varies  between  twelve  hours  and  three  or 
four  days.  The  third  stage  is  called  the  stage  of  collapse  or 
exhaustion  in  fatal  cases.  If  death  do  not  take  place,  the  third 
stage  is  the  stage  of  convalescence.  The  duration  of  the  disease 
varies  between  three  and  nine  clays.  The  average  duration  is 
less  than  a  week  (Flint  and  Looinis). 

Treatment. — There  is  no  specific  remedy  for  yellow  fever. 
Patients  should  take  to  the  bed  at  once.  Free  ventilation,  clean- 
liness and  cold  sponging  are  useful.  Mercury  has  been  tried. 
Ice  may  be  swallowed.  The  acetate  of  lead  with  opium  has  been 
much  extolled  to  prevent  black  vomit.  Milk  with  lime-water  is 
probably  the  best  article  of  diet.  Great  restlessness  calls  for 
opium.     Alcoholic  stimulants  may  be  given  (Flint  and  Loomis). 


CHAPTER  III. 
MEDICAL  DISEASES  OF  WOMEN. 


BY  W.  J.  GILLETTE,  31.  D. 


AMENORRHEA. 

The  term  arnenorrhoea  signifies  either  an  entire  absence,  a 
less  than  normal  amount,  or  an  habitual  delay  of  the  return  of 
the  menstrual  discharge.  To  those  cases  in  which  menstruation 
has  never  become  established,  the  term  primary  arnenorrhoea  is 
applied,  and  secondary  arnenorrhoea  to  those  in  which  menstrua- 
tion has  been  once  established  but  has  either  completely  or  in 
great  measure  disappeared. 

For  the  proper  establishment  of  menstruation  it  is  necessary 
that  the  sexual  organs  be  properly  developed  and  that  there  be 
sufficient  nutrition  and  vigor  of  the  general  system  to  sustain  it. 
The  primary  form  of  arnenorrhoea  is  usually  due  to  a  lack  of  de- 
velopment of  the  uterus  and  ovaries  which  remain  in  an  infantile 
condition.  It  is  also  possible  that  there  may  be  -an  entire  ab- 
sence of  the  ovaries  and  uterus.  The  causes  that  operate  to  pro- 
duce secondary  arnenorrhoea  will  also  act  to  produce  the  primary 
form.  Secondary  arnenorrhoea  is  occasioned  by  any  constitu- 
tional derangement  of  the  system  which  tends  to  greatly  lower 
the  vitality,  as  chlorosis,  Bright's  disease,  malaria,  diabetes,  can- 
cer, tuberculosis,  and  any  of  the  acute  fevers  as  well  as  syphilis. 
The  influence  of  the  nervous  system  is  also  a  great  factor  in  the 
production  of  secondary  arnenorrhoea,  how  else  can  we  account 
for  the  frequently  observed  temporary  suppressions  of  menstrua- 
tion, as  a  result  of  fright,  in  the  insane,  in  prisoners,  in  women 
taking  sea  voyages  and  often  in  the  unmarried  who  live  irregular 


AMENORRHEA.  611 

lives  and  have  subjected  themselves  to  the  danger  of  pregnancy. 
Obesity  and  plethora  are  often  observed  coincidentally  with 
amenorrhoea  possibly,  standing  in  a  causative  relation.  In  the 
consideration  of  any  case  of  secondary  amenorrhoea,  the  possi- 
bility of  pregnancy  being  the  cause  of  the  suppression  should 
never  be  lost  sight  of.  Any  of  the  inflammatory  diseases  of  the 
uterus  and  adnexa,  either  chronic  or  acute,  together  with  sujDer- 
involution  or  long  standing  sub-involution,  mutilations  of  the 
uterus  and  ovaries  and  even  the  too  vigorous  use  of  the  curette 
and  the  cautery  have  been  followed  by  amenorrhoea.  Menstrua- 
tion always  disappears  after  the  complete  removal  of  the  uterus 
and  in  a  large  majority  of  cases  after  the  ovaries  and  tubes  have 
been  removed;  occasionally,  however,  it  happens  that  menstrua- 
tion continues  after  complete  removal  of  the  ovaries,  usually  ceas- 
ing after  a  year  or  two. 

Tumors  of  the  ovary  do  not  usually  interfere  with  men- 
struation, at  least  not  until  a  very  late  date,  or  unless  both 
ovaries  are  involved,  and  finally  become  destroyed  completely 
by  the  growths,  when  menstruation  may  cease.  An  imperforate 
hymen,  cervix  or  vagina  may  prevent  the  appearance  of  the 
menstrual  now,  but  these  cases  can  easily  be  diagnosed  from 
amenorrhoea  due  to  lack  of  development  of  the  uterus  and 
ovaries,  by  the  fact  that  the  patient  has  the  usual  monthly  re- 
curring symptoms  of  menstruation,  pain,  discomfort,  etc.,  and  on 
examination  a  well  marked  bulging  may  be  discovered  at  the 
vulva  and  sometimes  a  tumor  extending  above  the  pubis.  Most 
of  these  cases  are  due  to  imperforate  hymen  and  are  easily  cured 
by  incising  the  hymen  under  antiseptic  precautions  and  allowing 
the  retained  menstrual  blood  to  escape,  after  which  the  regular 
monthly  period  becomes  established.  The  sudden  discharge  of 
a  retained  menstruation  is  not  entirely  free  from  danger,  and  it 
is  best  to  allow  it  to  come  away  slowly,  afterwards  washing  with 
an  antiseptic  fluid,  as  a  solution  of  bichloride  of  mercury  (1  to 
5000). 

The  diagnosis  as  to  whether  a  case  of  primary  amenorrhoea 
is  congenital  or  not,  is  of  importance.  If  it  be  congenital,  an 
examination  reveals  the  absence  or  abnormality  of  the  internal 
sexual  organs.    Externally  the  genitals  may  be  normally  formed, 


612  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

the  pubes  covered  with  hair  and  the  mamma?  well  developed- 
This  class  of  cases  may  develop  masculine  characteristics,  the 
upper  lip  covered  with  hair,  and  the  muscular  and  mental  char- 
acteristics more  nearly  approaching  the  male  than  the  female; 
but  often  there  is  nothing  in  the  general  appearance  to  indicate 
anything  sexually  wrong.  In  the  second  class  of  cases  the  pubes 
remain  bare,  the  mammaB  undeveloped  and  there  seems  to  be  a 
complete  absence  of  sexual  development,  with  always  a  general 
appearance  of  masculinity.  These  do  not  develop  symptoms  of 
any  hind  indicating  the  trouble.  Nothing  can  be  done  to  relieve 
the  condition  when  distinctly  congenital.  Cases  not  congenital 
but  of  delayed  development  may,  if  treated  while  the  patient  is 
yet  young,  be  benefited  by  removing  the  cause  of  the  delay, 
which  will  usually  be  found  to  be  general  debility  with  iinpro}> 
er  mode  of  living.  Remedies  directed  to  bettering  the  consti- 
tutional conditions,  with  sometimes  local  stimulation  of  the 
nterus  by  the  use  of  electricity,  the  dilating  from  time  to  time  of 
the  cervix,  etc.,  will  be  found  of  value.  Internal  remedies,  such 
as  the  bitter  tonics,  gentian,  columbo,  etc.,  with  iron,  mix  vomica 
and  cod- liver  oil,  are  very  useful. 

Secondary  amenorrhoea  may  be  occasioned  by  a  variety  of 
pathological  conditions,  as  indicated  above,  and  the  treatment  of 
it  will  vary,  according  to  the  cause.  When  due  to  any  of  the 
debilitating  diseases,  these  diseases  should  be  treated,  and  little 
attention  paid  to  the  menstruation.  As  soon  as  health  is  re-es- 
tablished, menstruation,  as  a  rule,  will  recur.  The  amenorrheea 
of  chlorosis  is  best  treated  by  giving  iron  and  arsenic  with  saline 
purgatives,  or  by  giving  arsenic  for  a  time,  followed  by  iron  and 
aloes  pills.  I  have  found  Blaud's  pill  a  most  useful  one  in  these 
cases.  Manganese  has  been  recommended,  but  its  value  is  ques- 
tionable, and  if  it  is  of  value,  it  is  certainly  not  the  equal  of 
iron.  Potassium  permanganate,  tansy,  savine  or  saffron  have 
been  recommended,  but  they  are  not  entirely  free  from  danger, 
and  should  seldom,  if  ever,  be  given. 

The  rjrognosis  is  serious  or  not,  depending  entirely  on  the 
pathological  condition  causing  the  amenorrheea.  In  young  girls 
it  is  usually  more  favorable  than  in  women  who  have  borne 
children. 


DYSMENORRHEA.  613 

Sudden  suppression  of  the  flow  during  a  monthly  period  is  most 
frequently  caused  by  a  disturbance  of  the  circulation,  by  expos- 
ure to  cold,  by  excessive  exertion,  or  by  great  mental  emotion, 
and  this  sudden  stoppage  may  be  followed  by  inflammation  of  the 
ovaries,  uterus  and  tubes,  if  the  flow  is  not  promptly  re-established. 
The  treatment  at  first  should  be  directed  to  the  re-establishment 
of  the  circulation  through  its  proper  channels,  Warm  sitz -baths 
and  hot  drinks  should  be  given,  the  patient  placed  in  bed,  with 
hot  fomentations  over  the  abdomen.  A  cathartic  may  be  given 
with  advantage.  If  the  menstruation  fails  to  be  re-established, 
as  soon  as  the  period  has  passed  means  should  be  adopted  for 
the  relief  of  the  uterine  congestion,  as  hot  douches,  warm  sitz- 
baths,  the  application  of  leeches  to  the  cervix,  or  scarifying. 
Exercise  should  be  restricted. 

DYSMENORRHEA. 

Dysmenorrhea,  or  painful  menstruation,  is  due  to  patho- 
logical conditions  which  may  be  grouped  roughly  under  four 
heads : 

1.  Defective  nerve  supply,  or  the  neuralgic. 

2.  Inflammatory. 

3.  Mechanical  obstruction  to  the  flow. 

4.  The  membranous  variety,  in  which  the  mucous  membrane 
of  the  uterus,  instead  of  undergoing  fatty  degeneration,  is  cast 
off  entire  or  in  shreds. 

The  neuralgic  variety  seems  to  be  due  entirely  to  a  general 
neurasthenic  condition,  the  uterus  and  adnexa  presenting  no  dis- 
coverable pathological  lesions  that  could  account  for  the  severe 
pain.  This  class  of  patients  is  usually  hysterical  and  suffer  from 
nervous  troubles.  The  digestion  is  bad  and  they  are  usually 
anaemic.  Hyperesthesia  over  the  lower  abdomen  will  usually  be 
observed  even  during  the  inter-menstrual  period. 

The  diagnosis  must  be  based  upon  the  fact  that  no  lesion  of 
the  uterus  can  be  found  and  upon  the  general  condition  of  neu- 
rasthenia. Often  this  trouble  is  associated  with  rheumatism. 
Prognosis  is  not  very  favorable  but  in  time  with  careful  treat- 
ment the  trouble  may  disappear.     The  indications  for    treatment 


614  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

are  general  rather  than  local.  If  the  patient  suffer  from  rheu- 
matism, tincture  of  guaiac,  colchicum,  or  salicylate  of  sodium  will 
be  found  of  benefit.  Tonics,  out- door  exercise,  and  a  good 
nourishing  diet  with  cod-liver  oil,  will  aid  greatly.  In  the  purely 
ana3inic  and  neurasthenic  cases,  very  often  the  continued  use  of 
chlorate  of  potash,  iron,  and  the  bitter  tonics  will  be  found  of 
value.  For  the  actual  suffering  some  of  the  coal  tar  derivatives, 
as  antipyrin  and  phenacetin,  or  pulsatilla  given  every  hour  will 
greatly  relieve.  Opium  and  alcohol,  although  they  promptly  re- 
lieve, should  not  be  given  for  the  habit  of  their  continued  use 
may  be  acquired. 

Inflammatory  dysmenorrhea  is  a  result  of  inflammation  of 
the  uterus  and  adnexa.  Whenever  the  uterus  becomes  inflamed 
it  is  seldom  that  this  inflammation  does  not  extend  to  the  ovaries 
and  tubes,  sometimes  producing  chronic  pelvic  peritonitis  with 
accumulations  of  pus.  Whenever  the  inflammation  is  largely 
limited  to  the  uterus  the  pain  begins  with  the  flow,  and  contin- 
ues while  it  lasts;  but  if  the  inflammation  has  attacked  the  tubes 
and  ovaries  the  pain  will  begin  three  or  four  or  more  days  before 
the  flow  starts  and  is  usually  then  in  a  large  measure  relieved. 
The  pain  of  menstruation  clue  to  inflamed  ovaries  and  tubes  is 
usually  most  marked  on  the  left  side,  radiating  down  the  thigh 
and  much  increased  when  the  patient  walks  about.  These  cases 
have  usually  a  history  of  sterility  and  though  much  may  be  done 
for  them  in  the  way  of  palliative  treatment,  yet  a  complete  cure 
aside  from  the  removal  of  the  ovaries  and  tubes,  is  usually  not  to 
be  looked  for.  Headache,  nervousness,  and  some  fever  usually 
accompany  the  pain,  and  the  patient  is  sometimes  much  nau- 
seated. 

The  diagnosis  will  be  indicated  by  the  character  of  the  pain 
and  the  evidences  of  inflammation  within  the  pelvis. 

The  treatment  will  be  that  indicated  for  inflammation  of  the 
pelvic  organs.  The  bowels  should  be  kept  open  with  salines 
and  the  patient  kept  in  bed  during  the  menstrual  period,  Hot 
fomentations  may  be  applied  to  the  lower  part  of  the  abdomen. 
To  control  the  pain,  some  one  of  the  coal-tar  derivatives  may  be 
given,  as  antipyrin,  phenacetin,  etc.  Opium  and  alcohol  should 
be  withheld.     During  the  intermenstrual   period,  treatment  for 


DYSttEXORRHCEA.  615 

the  pelvic  inflammation  should  be  persistently  followed,  as  hot 
douches,  painting  the  roof  of  the  pelvis  with  iodine,  using 
tampons  of  boro-glyceride,  etc.  Ichthyol  is  a  most  valuable 
remedy  in  these  cases  used  as  a  suppository,  or  a  dressing  within 
the  vagina. 

Any  condition  which  interferes  with  the  free  discharge  of 
the  flow  produces  what  is  known  as  mechanical  dysmenorrhoea. 
These  obstructions  are  various,  and  include  stenosis  of  the  cervix 
at  either  the  internal  or  external  os,  acute  flexions,  or  23ressure  of 
tumors  as  fibroids  or  polypi  that  have  found  lodgment  in  the 
cervical  canal.  Under  this  head  may  be  classed  cases  of  imper- 
fect development  of  the  uterus,  and  usually  with  anteflexion. 
The  pain  of  obstructive  dysmenorrhoea  is  spasmodic  in  character, 
blood  accumulates  behind  the  obstruction,  and  the  contractions 
of  the  uterus  to  force  it  by  the  obstruction,  occasion  it.  As  soon 
as  the  blood  is  discharged  the  contractions  cease,  the  patient  is 
relieved  and  so  remains  until  the  accumulated  blood  is  again 
forced  off.  The  paroxysmal  character  of  the  pain  will  assist  in 
making  a  diagnosis. 

Prognosis  ma}^  be  good  or  bad,  depending  entirely  upon  our 
ability  to  relieve  the  obstruction.  Medicines  will  be  of  but  little 
avail;  this  class  of  cases  of  necessity  can  only  be  assisted  by  the 
surgeon.  If  the  stenosis  be  at  either  os,  a  thorough  dilation  of 
the  canal  may  cure.  Dilation  and  curettment  may  also  be  em- 
ployed when  the  uterus  is  flexed.  Flexions  of  the  uterus  are 
nearly  always  accompanied  by  congestion  of  the  mucous  mem- 
brane.    Removal  of  growths,  if  such  exist,  must  be  done. 

Membranous  dysmenorrhoea  is  that  form  in  which  after  a 
time  the  paroxysm  of  pain  is  followed  by  expulsion  of  a  mem- 
brane from  the  uterus.  These  membranes  show  a  smooth  reddish 
inner  surface  upon  which  the  orifices  of  the  utricular  glands  may 
be  seen  by  the  naked  eye  and  an  external  rough,  uneven  surface 
which  appears  as  though  torn  from  its  connections,  and  at  times 
contains  small  blood  clots.  In  many  cases  the  membrane  is  a 
complete  sac  containing  three  openings  corresponding  to  the  os 
uteri  and  orifices  of  the  tubes. 

The  symptoms  of  membranous  dysmenorrhoea  are  not  differ- 
ent from  those  of  other  forms  of  dysmenorrhoea.     The  pain,  how- 


616  A    COMPENDIUM    OF    PRACTICAL     MEDICINE 

ever,  is  extremely  severe,  paparoxvsnial  in  choracter,  usually  the 
most  severe  just  before  the  membrane  is  expelled.  In  nervous 
patients,  hysterical  conditions  are  not  uncommon.  The  now  may 
be  scanty  in  fact  usually  is.  The  membrane  is  cast  off  from  the 
second  to  the  fifth  day.  Occasionally  the  membrane  is  cast  off 
without  pain.  Patients  with  membranous  clysmenorrhcea  are 
usually  sterile,  but  if  pregnancy  should  supervene,  they  may 
afterwards  menstruate  normally,  though  cases  are  reported  where 
pregnancy  did  not  effect  a  cure.  Prognosis  is  not  very  favor- 
able. 

Treatment. — Many  remedies  have  been  employed  for  this 
trouble  and  sometimes  with  benefit.  .  The  most  popular  method 
is  thoroughly  dilating  and  curretting  the  uterus.  Cauterization 
of  the  uterine  canal  with  nitrate  of  silver,  tincture  of  iodine,  or 
carbolic  acid  may  be  tried.  The  introduction  of  suppositories 
containing  iodoform  has  been  recommended  by  Skene.  Dilating 
the  uterus,  curretting  and  cauterzing  the  endometrium  with  the 
Paquelin  cautery,  followed  by  packing  the  uterus  with  iodoform 
gauze  has  met  with  success.  For  the  immediate  relief  of  pain 
the  same  remedies  as  are  employed  in  the  other  forms  of  dys  - 
menorrhcea  should  be  employed.  A  resort  to  opium  is  only  to 
be  thought  of  when  all  other  remedies  have  failed  to  relieve. 

LEUCORRH(EA. 

By  the  term  leucorrlicea  is  commonly  meant  any  discharge 
other  than  blood  coining  from  the  genitals,  though  literally  the 
term  means  a  white  discharge.  These  discharges  from  the  vagina 
are  popularly  called  the  "whites.1''  They  may  come  from  any 
point  along  the  genital  mucous  membrane,  from  the  vulva,  the 
vagina,  the  cervix,  or  the  body  of  the  womb,  and  are  caused  by 
many  different  pathological  conditions,  but  there  are,  however, 
forms  of  leucorrhoea  which  may  be  regarded  as  physiological, 
such  as  the  large  quantities  of  mucus  poured  out  often  during 
pregnancy.  The  abundant  discharge  of  mucus  preceding  and 
following  menstruation  cannot  be  considered  pathological.  Also 
in  girls  suffering  from  amenorrhcea  there  is  in  many  instances 
from  time  to  time  profuse  discharge  of  mucus  which  takes  the 


LEUCORRIKEA.  617 

place  of  proper  menstruation  and  has  been  called  " menstrual 
leucorrhoea.'1'1  These  forms  of  lencorrhcea  require  no  treatment. 
A  very  considerable  number  of  cases  of  leucorrhoea  may  be  re- 
garded as  catarrh  of  some  portion,  or  all,  of  the  genital  mucous 
membrane,  very  much  of  the  same  character,  as  catarrh  of  other 
mucous  membranes,  as  of  the  resjnratory  tracts  or  the  alimentary 
canal.  In  the  respiratory  tract  we  have  bronchitis,  laryngitis 
and  nasal  catarrh;  in  the  alimentary  canal,  diarrhoea. 

What  is  true  of  these  membranes  is  also  true  of  the  vaginal 
and  uterine,  they  alike  are  influenced  by  climatic  changes  and  a 
severe  leucorrhoea  may  be  lighted  up  by  exposure  to  cold,  check- 
ing suddenly  the  secretions  of  the  skin,  or  while  attending  to 
calls  of  nature,  draughts  of  air  blowing  over  the  exposed  mucous 
membrane  of  a  patulous  vagina  may  give  rise  to  it.  Leucorrhoea 
is  not  uncommon  in  women  suffering  from  tuberculosis,  or  any 
strumous  diathesis,  and  often  in  these  cases  the  mucous  mem- 
brane presents  no  discoverable  anatomical  lesion.  Sometimesy 
however,  the  mucous  membrane  is  attacked  by  tubercle,  and  then 
severe  lesions  present.  Hereditary  or  acquired  syjmilis  will 
produce  leucorrhoea  of  a  very  intractable  form  and  it  often  coex- 
ists with  gout  and  rheumatism.  Whenever  the  tissues  are  badly 
nourished  and  the  patient  is  greatly  debilitated,  mucus  discharge 
from  the  vagina  is  easily  induced.  All  of  the  foregoing  influ- 
ences will,  it  is  true,  induce  leucorrhoea,  but  by  far  the  most  im- 
portant and  most  frequent  cause  of  the  discharge  is  some  uterine 
disorder  marked  by  lesion  of  structure  as  the  inflammatory  dis- 
eases of  the  vagina  and  uterus,  such  as  sj)ecific  (gonorrhoea)  and 
non-specific,  tumors  (malignant  and  non-malignant),  displace- 
ments and  lesions  of  structure,  such  as  those  following  confine- 
ments. Hence,  leucorrhoaa  should  be  considered,  especially  if 
constant,  as  extremely  significant  of  uterine  disease.  If  intermit- 
tent entirely  disappearing  from  time  to  time,  it  is  not  so  likelv 
to  be  an  indication  of  uterine  disease. 

The  occurrence  of  leucorrhoea  in  children  is  deserving  of 
especial  attention.  It  sometimes  follows  the  acute  exanthematous 
diseases  especially  scarlatina.  Ascarides  sometimes  find  their 
way  from  the  rectum  into  the  vagina,  and  set   up  a  severe  irrita- 


618  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tion  with  discharge.  Strumous  children  are  very  subject  to  this 
trouble. 

Prognosis. — This  must  depend  upon  the  cause  entirely. 

Treatment. — If  the  condition  depend  upon  a  constitutional 
cause,  the  treatment  must  be  general  as  well  as  local;  but  if  to  a 
local  cause,  treatment  may  be  confined  to  the  seat  of  the  disease. 
The  digestion  and  the  bowels  should  be  carefully  attended  to. 
Good  food,  warm  clothing,  and  plenty  of  out- door  exercise  will 
aid  in  restoring  the  vigor  of  the  general  constitution.  Frequent 
bathing,  and  rubbing  the  surface  thoroughly  with  towels  should 
not  be  neglected.  In  strumous  cases,  tonics,  such  as  gentian, 
Colombo,  nux  vomica,  with  iron  and  cod- liver  oil,  will  be  of 
benefit.  Aletris  cordial,  hydrastis,  and  cimicifuga  have  been 
recommended  as  having  the  effect  of  directly  checking  the  flow. 
The  local  treatment  may  consist  of  applications  to  the  parts  of 
tincture  of  iodine,  solutions  of  nitrate  of  silver,  carbolic  acid, 
chloride  of  zinc,  etc.  I  have  found  in  certain  cases  great  benefit 
from  the  use  of  suppositories  made  after  the  following  formula: 

j&     Acidi  tannici 

Acidi  gallici 

Bismuthi  subnitratis aa gr.  iij-v. 

Olei  theobroma? q.  s — M. 

Ft.  suppositorium  no.  i. 
Sig. :  Insert  into  the  vagina  after  a  douche  of  warm  water  at  bed 
time. 
These  suppositories  used,  one  daily,  for  a  time  check  the  se- 
cretions and  often  effect  a  cure.     If  the  trouble  arises  from    lac- 
erations of  the  cervix,  these  should  be   restored   by    operations. 
If  the  trouble  is  due  to  endometritis  or  cervicitis    a    currettment 
of  the  uterus  will  often  effect  a  cure.     In  any  case    the    cause  of 
the  trouble  should  be  diligently  sought  out  and  removed. 

VAGINITIS. 

Vaginitis  or  colpitis  are  terms  used  to  designate  inflamma- 
tion of  the  vagina.  There  are  two  forms,  the  acute  and  chronic. 
If  the  disease  lasts  a  period  longer  than  three  weeks  or  a  month, 
it  is  then  spoken  of  as  chronic,  prior  to  this  time  as  acute.  Of 
the  varieties  of  vaginitis  we  have  the  catarrhal  in  which  inflam- 


VAGINITIS.  619 

mation  of  the  mucous  membrane  is  only  so  severe  as  to  occasion 
a  discbarge  of  mucus  or  muco- purulent  matter.  Under  this  head 
are  grouped  nearly  all  of  the  ordinary  inflammations  of  the  va- 
gina, including  the  gonorrhoeal.  When  the  inflammation  is  of 
such  character  that  a  solid  exudate  is  thrown  out  or  into  the 
mucous  membrane  we  have  what  is  termed  exudative  vaginitis. 
This  form  of  inflammation  is  due  to  diphtheria.  Sometimes  the 
inflammation  is  situated  within  the  connective  tissue  about  the 
vagina.  It  is  then  known  as  the  phlegmonous  variety  and  is 
sometimes  so  severe  as  to  occasion  the  sloughing  of  a  great  por- 
tion or  all  of  the  vaginal  wall. 

Catarrhal  vaginitis  may  occur  from  exposure  to  cold,  from 
infection,  from  the  introduction  of  foreign  substances,  from  irri- 
tating injections,  etc.  In  children  it  may  be  caused  by  the  pres- 
ence of  ascarides,  by  neglect  of  cleanliness,  and  by  improper  hand- 
ling of  the  parts.  Vaginitis  often  follows  attacks  of  the 
exanthematous  diseases,  but  its  most  common  cause  is  gonorrhoeal 
infection. 

Gonorrhoeal  vaginitis  is  very  apt  to  extend  from  the  cervical 
canal  to  the  endometrium,  and  from  thence  to  the  tubes  and 
ovaries.     It  is  also  apt  to  spread  to  the  urethra. 

Among  the  causes  of  vaginitis  are  excessive  coition  and  mas- 
turbation. Old  women  sometimes  are  troubled  with  a  very 
intractable  form,  the  cause  of  which  it  is  difficult  to  ascribe  to 
anything  but  old  age. 

The  symptoms  of  vaginitis  are  those  of  inflammation  else- 
where, as  heat,  pain,  redness  and  a  feeling  of  general  discomfort. 
In  the  acute  elevation  of  temperature  frequently  happens. 
Urination  gives  a  sense  of  smarting.  On  examination  the 
mucous  membrane  will  be  found  to  be  red  and  swollen.  Shortly 
after  the  onset  of  the  trouble  a  discharge  of  mucus  begins  from 
the  membrane,  soon  followed  by  pus.  If  the  urethra  is  involved 
as  it  is  likely  to  be,  pressure  along  it  with  the  finger  will  usually 
be  followed  by  the  discharge  of  a  few  drops  of  pus  from  the 
meatus.  If  the  inflammation  does  not  subside  within  three  or  at 
most  four  weeks,  it  is  said  then  to  have  become  chronic.  At  this 
time  usually  the  symptoms  will  have  in  large  measure  subsided, 
except  the  discharge,  which  may  continue  copious  and  purulent. 


620  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Gonorrhoeal  vaginitis  is  particularly  liable  to  become  chronic 
The  diagnosis  of  vaginitis  is  readily  made  out  on  examination 
with  the  speculum  and  the  vivid  red  membrane  is  at  once  noted 
with  the  discharge.  Care  should  always  be  exercised  that  a 
diagnosis  of  vaginitis  be  not  made  from  the  discharge  alone,  for 
that  may  come  from  the  interior  of  the  womb,  from  a  pelvic 
abscess,  from  malignant  growths,  etc.  The  question  often  arises, 
can  we  say  with  certainty  whether  a  given  case  of  vaginitis  is  of 
gonorrhoeal  origin  or  not.  There  has  been  much  controversy 
regarding  the  matter,  but  the  best  authorities  affirm  that  the 
presence  of  gonoccoci  is  conclusive  proof  of  gonorrhoeal  origin. 

Prognosis. — Is  good  in  a  large  proportion  of  cases,  but  when 
it  becomes  chronic  it  may  last  for  years. 

Treatment. — Patients  with  acute  vaginitis  should  remain  in 
bed  or  at  least  keep  quiet  while  the  acute  symptoms  last.  The 
bowels  should  be  kept  open  with  salines,  the  diet  restricted,  and 
hot  water  injections  given  twice  daily.  If  the  parts  are  much 
swollen,  poultices  of  emollient  substances,  as  linseed  meal  or 
chamomile  flowers,  may  be  applied.  Tampons  saturated  with 
glycerine  and  laudanum  may  be  inserted,  giving  much  comfort 
to  the  patient.  After  the  acute  symptoms  have  subsided,  solu- 
tions of  mercury  bichloride  (1  to  5000)  may  be  injected  with 
benefit.  Solutions  of  permanganate  of  potassium  are  also  recom- 
mended as  injections.  In  this  stage  of  the  trouble  I  have  found 
suppositories  containing  tannic  and  gallic  acid  with  sub-nitrate 
of  bismuth  to  be  of  great  value.  Internally  ol.  santal,  bals. 
copaiba  and  cubebs  may  be  given  with  benefit. 

METRITIS. 

We  understand  by  the  term  metritis  an  inflammation  of  the 
uterus.  As  of  inflammations  elsewhere  we  recognize  the  acute 
and  chronic  forms.  Of  these  forms  there  has  been  by  different 
authors,  a  variety  of  classifications  which  will  not  be  here  con- 
sidered. Metritis  is  one  of  the  most  common  troubles  of  the 
uterus.  A  variety  of  terms  have  been  applied  to  inflammations 
of  the  uterus  designed  to  indicate  the  part  of  it,  involved  in  the 
trouble  as,  endometritis,  meaning    inflammation    of    the    mucous 


METRITIS.  621 

membrane  lining  the  uterus ;  parenchymatous  or  corporeal  metri- 
tis, inflammation  of  the  muscular  portion  or  body;  cervicitis,  in- 
flammation of  the  cervix  and  endocervicitis,  inflammation  of  the 
lining  membrane  of  the  cervix.  Seldom,  if  ever,  does  the  body 
of  the  uterus  (the  muscular  layer)  become  inflamed  except  as 
an  extension  of  the  disease  from  the  mucous  membrane.  The 
mucous  membrane  of  both  the  body  of  the  uterus  and  the  cervix 
may  be  quite  severely  inflamed  for  a  long  period  of  time  without 
its  extension  to  the  muscular  layer. 

Metritis  is,  in  the  vast  majority  of  cases,  due  to  either  gon- 
orrhoea, or  is  a  sequence  of  the  puerperal  state,  but  may  be  due  to 
other  causes  as,  gynecological  operations,  the  introduction  of  a 
sound,  currettment,  etc.,  when  done  without  proper  aseptic  pre- 
cautions; or  it  may  be  caused  by  exposure  to  cold  and  wet, 
especially  at  the  time  of  menstruation.  Metritis  sometimes  fol- 
lows the  exanthematous  diseases  as  well  as  typhoid  fever  and 
syphilis. 

Symptoms. — The  acute  stage  of  metritis  is  accompanied  by 
fever,  the  uterus  is  painful  to  the  touch,  and  the  patient  com- 
plains of  cramp -like  pains  in  the  lower  part  of  the  abdomen. 
Nausea  and  vomiting  are  usual,  and  diarrhoea,  with  painful 
urination.  Menstruation  is  often  profuse,  but  is  sometimes  com- 
pletely suppressed.  With  these  symptoms  is  an  abundant  dis- 
charge of  purulent  matter  from  the  uterus.  Especially  is  this 
true  when  the  metritis  is  due  to  gonorrhoea.  On  vaginal  exam- 
ination the  uterus  is  seen  to  be  inflamed,  and  is  very  tender  to 
the  touch.  The  prognosis  is  usually  favorable,  but  the  disease 
may  extend  to  the  tubes  and  ovaries,  when  it  becomes  difficult  to 
cure.  If  it  continues  three  or  four  weeks,  becoming  chronic,  the 
probability  of  a  rapid  and  complete  cure  is  greatly  diminished, 
and  especially  if  there  is  evidence  that  it  has  extended  to  the 
tubes  and  ovaries. 

Treatment  of  Acute  Metritis. — The  patient  should  remain  in 
bed  while  the  acute  symptoms  continue.  To  relieve  the  pain, 
heat  should  be  applied  to  the  abdomen.  Sometimes  the  applica- 
tion of  cold  in  the  acute  stage  (as  an  ice  bag  to  the  lower  part  of 
the  abdomen)  will  give  comfort,  but  cold  should  not  be  applied 
if  there  is  menstrual  suppression.     Douches  of  plain  hot  water 


622  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

should  be  given  as  often  as  three  times  daily  or  more  frequently 
if  they  give  comfort.  Sometimes  hot  water  is  not  well  borne, 
then  tepid  water  should  be  tried.  Flax-seed  and  slippery  elm 
have  been  recommended  as  a  valuable  addition  to  the  water.  If 
the  pain  is  very  severe  it  may  be  necessary  to  administer  an 
opiate,  which  is  best  given  in  the  form  of  a  suppository.  Tam- 
pons saturated  with  boroglyceride  and  glycerine  in  the  propor- 
tion of  oj.  boroglyceride  to  O.j.  of  glycerine,  introduced  into  the 
vagina,  will  produce  a  profuse  watery  discharge  and  relieve  the 
congestion  and  pain.  Ichthyol  and  glycerine  may  be  used  in  the 
same  manner  with  benefit. 

Gonorrheal  metritis  is  treated  best  by  washing  out  the 
uterus  once  a  day  with  bichloride  solution  (1  to  2,000),  until  the 
acute  symptoms  have  subsided,  when  the  endometrium  may  be 
painted  (twice  weekly)  with  a  10  per  cent,  solution  of  nitrate  of 
silver.  Curretting  the  uterus  and  packing  with  iodoform  gauze 
is  effective.  The  gauze  acts  as  a  drain  and  keeps  the  uterus 
free  from  pus.  If  these  more  active  methods  of  treatment  cannot 
be  adopted  in  a  given  case  of  gonorrhoeal  metritis,  the  treatment 
for  acute  metritis  not  of  gonorrhoeal  origin,  as  described,  can  be 
adopted,  together  with  the  internal  administration  of  anti-blenor- 
rhagic  drugs,  as  bals.  copaiba?,  ol.  santal,  etc.,  though  these  reme- 
dies should  be  given  in  smaller  doses  than  to  men. 

Chronic  Metritis  proceeds  from  the  acute  form,  or  is  slowly 
developed  from  a  lesion  of  structure  at  some  point  of  the  uterus, 
which  allows  of  the  introduction  of  infection.  The  most  com- 
mon form  of  lesion  productive  of  chronic  metritis  are  the  lacera- 
tions of  the  cervix,  so  frequently  following  child  bearing. 
Usually  in  these  cases  the  uterine  tear  has  prevented  the  return 
of  the  uterus  to  its  normal  size  after  labor  and  a  condition  of 
subinvolution  exists.  The  whole  organ  may  be  involved  or  only 
the  cervix,  or  as  often  happens  the  inflammation  is  confined  to 
the  mucous  membrane  lining  the  cervix  and  is  then  called  e'ndo- 
cervicitis,  or  to  the  mucous  membrane  of  the  body,  then  called 
endometritis.  Tumors,  malignant  and  non-malignant,  may  act 
as  predisposing  causes  of  chronic  metritis.  A  condition  of 
hardening  sometimes  follows  loug  continued  inflammation  and 
anaemia  of  the  uterine  structure,  the  tissue  becoming  cicatricial  in 


METRITIS.  623 

character  when  it  is  known  as  uterine   sclerosis.     The    condition 
is  incurable  and  function  of  the  uterus  practically  ceases. 

With  chronic  metritis  we  have   the   prominent  symptom  of 
pain.     The  patient  often  complains  of  a  "bearing  down"  sensa- 
tion, is    troubled  with    cramps,  and  frequently  with  an  irrita- 
ble  bladder.     Dysmenorrhoea  is   usually  an   accompaniment  of 
metritis  with  prolonged  menstruation,  and  frequently  bloody  dis- 
charges in  the  interval  between  the   menstrual  periods.     Some- 
times, however,  in  very  weak  patients,  the   condition  is  accom- 
panied with  menstrual  suppression.     Usually  there   is  copious 
leucorrhoea,  and  the   appearance  of  this  discharge  is  character- 
istic.    From  the   cervix  it  resembles  much   the  -white  of  eggs, 
and  from  the  uterine  body  is  milky  in  appearance.     The  general 
symptoms  are,  loss  of  appetite,  with  nausea,  dyspepsia  and  con- 
stipation.    The  patient  often  loses  flesh,  becoming  anaemic  and 
and  weak.     Backache  and  pain  in  the  lower  abdomen  is  usual. 
The  patient  is  hysterical  and  melancholy,  and  usually  remains 
sterile.     On  vaginal  examination,   if  the  disease  is   a  result  of 
child-bearing,  we  find  the  os  patulous,  the  cervix  enlarged  and 
inflamed,  possibly  studded  with  hard  nodules    (the    follicle  of 
Naboth),  and  showing  evidences  of  laceration.     Care  should  al- 
ways be  taken  not  to  confound  cancer  with  inflammation.    When 
the  cervix  is  hardened  with  inflammation   and  the  follicles  en- 
larged, they  may  present  very  similar  appearances.     A  currette, 
however,  will  clear  up  the  diagnosis.     If  the  case  is  cancer,  on 
curettment  friable  tissue  is  always  brought  away.     If  inflamma- 
tion, the  tissues  are  firm,  and   the  currette  only  makes  the  part 
bleed,  and  denudes  it  of  a  little  mucous  membrane. 

Prognosis — Of  chronic  metritis  is  uncertain,  but  a  slow  and 
tedious  recovery  is  to  be  anticipated. 

Treatment. — Patients  suffering  from  endometritis  should  take 
plenty  of  rest.  Employment  that  requires  a  great  deal  of  exer- 
cise should  be  prohibited,  especially  work  with  sewing  machines. 
The  bowels  should  be  kept  open  and  sexual  intercourse  as  much 
as  possible  interdicted.  Bathing  frequently  should  not  be  neg- 
lected. A  sitz-bath  occasionally  will  be  found  of  benefit.  Hot 
water  douches  should  be  given  twice  daily.  If  the  cervix  is 
much  eroded,  painting  the   erosions  with   tinct.  iodine   comp.,  a 


624  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

solution  of  nitrate  of  silver,  carbolic  acid,  chloride  of  iron  or 
chloride  of  zinc  will  be  beneficial.  Iodine  is  most  commonly 
used.  Applications  of  iodine  may  also  be  made  from  time  to 
time  to  the  endometrium  with  a  bit  of  cotton  wrapped  upon  a 
probe.  If  the  remedies  above  recommended  fail  to  cure,  it  will 
be  best  to  thoroughly  dilate  the  uterus,  currette  the  endometrium, 
and  if  of  very  long  standing,  cauterize  it  with  the  actual  cautery; 
or  after  the  curettment  the  uterus  can  be  packed  with  iodoform 
gauze  or  a  drainage  tube  inserted  and  thoroughly  drained.  If 
the  cervix  is  lacerated  the  laceration  should  be  repaired.  If  the 
treatment  proves  of  no  avail  and  the  disease  has  extended  to  the 
tubes  and  ovaries  they  may  have  to  be  removed.  Constitutional 
treatment  should  not  be  neglected,  as  the  administration  of 
tonics,  looking  after  the  secretions,  etc. 


CHAPTER  IV. 
FIRST  HELP  IN  SURGICAL  EMERGENCIES. 


BY  J.  H.  POOLEY,  M.  D. 


Prefatory. — The  few  desultory  notes  on  various  discon- 
nected subjects  which  make  up  this  chapter  are  not  intended  as 
a  complete  discussion  of  any  subject,  but  simply  hints  which  may 
be  referred  to  in  an  emergency  and  suggest  some  line  of  conduct 
which  may  be  adopted  while  arrangements  are  made  for  regular 
and  permanent  treatment.  Nothing  new  is  offered,  nor  is  there 
any  pretense  to  novelty,  even  in  the  presentation  of  the  subject. 
But  sometimes  the  old  and  hackneyed,  if  apposite  to  the  case, 
and  easy  of  reference,  is  of  more  value  at  the  time  than  the  most 
learned  and  exhaustive  discussion.  If  these  suggestions  prove  in 
any  instance  of  assistance  to  the  young  doctor,  who  is  generally 
burdened  with  knowledge  which  he  does  not  know  how  to  use, 
they  will  not  have  been  written  in  vain. 

BURNS. 

The  extent  of  surface  affected  is  of  more  importance  than 
the  depth  or  destruction  of  tissue  involved.  When  a  very  large 
surface,  especially  over  the  trunk,  is  involved  the  prognosis  is 
grave.  The  first  attention  in  a  case  of  burns  includes  both  local 
and  general  treatment.  Locally,  tense  blisters  should  be  evacu- 
ated by  small  punctures  aud  gentle  pressure,  and  the  epidermis 
allowed  to  fall  down  over  the  abraded  surface.  Any  dressing 
that  will  exclude  air  will  answer  the  purpose,  though  if  con- 
venient carbolic  acid  may  be  added  both  for  its  anaesthetic  and 
its  antiseptic  properties. 


626  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Flour,  freely  sprinkled  over  the  surface  from  a  dredging 
box,  is  almost  always  available. 

Oil  of  any  kind  thickened  with  chalk,  whitning,  bismuth,  or 
any  similiar  substance  is  an  excellent  dressing.  The  so-called 
carron-oil  a  mixture  of  linseed  oil  and  lime  water  is  a  common 
application  and  efficient,  but  it  is  a  nasty  ill -smelling  dressing. 

Prof.  S.  D.  Gross  highly  recommended  common  white  paint 
reduced  to  a  proper  consistence  with  oil  and  freely  painted  over 
the  surface.  He  says  that  no  fear  need  be  entertained  of  the 
constitutional  effects  of  lead.  Cotton,  though  recommended  by 
some,  is  a  bad  dressing,  and  only  to  be  used  when  nothing  else 
can  be  had.  After  the  dressing,  whatever  it  is,  has  been  freely 
applied  on  pieces  of  soft  old  cloth,  it  should  be  retained  by  loose 
bandages.  The  pain  of  burns,  especially  of  the  superficial  kind, 
is  very  severe,  and  demands  the  administration  of  opium  or  some 
of  its  preparations.  These  may  be  given  freely  in  aduhs,  but  in 
children  great  care  is  necessary  in  their  use.  Shock,  and  in  child- 
ren convulsions,  are  common  in  severe  burns,  and  demand 
stimulants,  such  as  spirits,  hot  beef  tea,  etc.,  by  mouth  or 
rectum. 

In  cases  where  steam  or  heated  air  have  been  inhaled,  severe 
inflammation  of  the  mouth  and  fauces  may  result;  the  frequent 
administration  of  oil,  or  vaseline,  or  lard  will  give  relief;  if 
oedema  of  the  glottis  results,  tracheotomy  may  be  necessary  to 
save  life. 

COLD.     (Exposure  to). 

The  effects  of  intense  cold  may  be  either  general  or  local; 
the  first  result  of  general  exposure  to  cold  is  stimulating,  but 
this  is  quickly  followed  by  depression,  pallor  and  coldness  of  the 
surface,  with  pain  and  numbness,  followed  by  drowsiness,  which, 
if  indulged,  ends  in  coma  and  death.  Death  from  cold  resembles 
apoplexy. 

To  restore  a  person  insensible  from  exposure  to  cold,  the 
patient  should  be  placed  in  a  cool  room,  the  surface  rubbed  with 
snow,  or  flannel  cloths,  wet  with  whiskey  or  dilute  alcohol.  Arti- 
ficial respiration  must  be  resorted  to  in  extreme  cases.  When 
reaction  begins,  the  temperature  of  the  room  may  be  raised,  and 


COLD — DROWNING — DISLOCATION    AND    FRACTURES.  627 

the  body  wrapped  up  in  warm  blankets.  Stimulants  should  be 
administered  in  moderate  doses,  at  short  intervals;  if  the  patient 
cannot  swallow,  they  may  be  given  per  rectum.  Persevere  in 
these  efforts,  as  some  cases  have  been  rescued  from  apparent 
death  only  after  hours  of  vigorous  treatment. 

The  local  effects  of  cold  are  divided  according  to  their  sever- 
ity, into  chilblains,  and  frost-bite.  The  frozen  part  at  first  ap- 
pears red,  purple,  or  mottled,  afterwards  white  or  waxy,  and  is 
hard  and  stiff.  Care  must  be  taken  not  to  restore  circulation  too 
rapidly.  First  rub  the  part  with  snow,  afterwards  with  the  warm 
hand,  or  some  stimulating  liniment. 

If  gangrene  results,  treat  locally  with  antiseptic  dressings 
and  await  results.  Constitutionally  good  food,  tonics,  and 
anodynes  to  relieve  pain  if  present,  are  indicated. 

DROWNING. 

To  resuscitate  a  person  in  a  condition  of  suspended  anima- 
tion from  drowning,  the  body  should  first  be  inverted,  held  head 
downward  for  a  few  seconds,  to  let  the  water  run  out  of  the 
mouth,  fauces,  and  (esophagus;  then  removed  to  a  warm  room,  and 
the  surface  dried  and  vigorously  rubbed  with  woolen  cloths. 
The  tongue  should  be  drawn  well  forward  and  artificial  respira- 
tion practiced  either  by  Marshal  Hall's  or  Sylvester's  method, 
care  being  taken  not  to  repeat  the  steps  of  the  process  too  rapid- 
ly. The  great  thing  in  these  cases  is  perseverance.  Vigorous 
efforts  should  be  kept  up  at  least  half  an  hour,  and  if  there  is  the 
least  encouragement,  much  longer.  When  reaction  begins  it  may 
be  favored  by  mustard  aj) plications  to  precordia  and  spine,  and 
hypodermic  injection  of  stry china  ^V  to  ^V  gr. 

DISLOCATIONS  AND  FRACTURES. 

Until  preparation  can  be  made  for  reduction  and  permanent 
dressing  of  these  injuries  the  limb  should  be  placed  in  a  com- 
fortable position  and  adequately  supported.  Care  and  gentle- 
ness should  be  exercised  in  the  removal  of  clothing;  it  is 
frequently  better  to  cut  the  clothes  along  seams,  than  to  attempt 
removal  in  the  ordinary  way.     As  a  temporary  splint  in  case  of 


628  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

fracture,  almost  anything  will  answer,  a  pasteboard  box,  a  maga- 
zine or  paper- covered  novel,  or  a  bundle  of  newspapers.  In 
fracture  of  the  lower  extremity  the  so-called  comforter  splints 
serves  an  excellent  purpose.  This  is  prepared  by  taking  an  or- 
dinary bed  comfort  and  spreading  it  flat  upon  a  table  or  the 
floor;  then  two  persons,  one  on  each  side,  roll  their  respective 
halves  into  as  compact  and  even  a  cylinder  as  possible.  The 
limb  is  then  placed  between  the  two  cylinders  thus  formed,  and 
tied  tightly  with  strips  of  bandage  or  handkerchiefs.  This 
makes  a  very  efficient  and  comfortable  splint,  for  the  first 
twenty-four  hours  or  more,  while  arrangements  are  made  for 
permanent  treatment. 

FOREIGN  BODIES  IN  EYE,  EAR  AND  NOSE. 

Foreign  bodies  such  as  small  fragments  of  coal- cinders, 
sand,  straw,  stone,  steel,  etc.,  may  be  either  lodged  in  the  folds  of 
the  conjunctiva,  particularly  the  superior  cul  de  sac,  or  impacted 
in  the  cornea.  In  the  first,  order  the  patient  to  look  up  while 
you  depress  the  lower  lid  and  carefully  explore  the  lower  cul  de 
sac.  Failing  to  find  it  here  you  direct  him  to  look  down,  then 
seizing  the  lashes  of  the  upper  lid  you  evert  it  over  the  end  of  a 
match,  point  of  a  pencil  or  your  finger-tip;  you  thus  expose  the 
whole  conjunctival  surface,  and  cannot  fail  to  find  the  particle  if 
present,  it  is  then  easily  removed  with  a  camels  hair  brush,  or 
the  corner  of  a  handkerchief. 

Pieces  of  granite  or  steel  frequently  become  firmly  impacted 
in  the  cornea  of  various  workmen.  The  eye  should  be  anaes- 
thetized by  a  few  drops  of  a  four  per  cent.solution  of  cocaine 
mur.,  when  the  body  can  be  easily  picked  out  with  a  cataract 
needle,  point  of  a  lancet  or  similar  instrument. 

Foreign  bodies  in  the  ear  are  generally  met  with  in  children 
who  often  mischievously  or  carelessly  thrust  such  things  as  but- 
tons, beads,  pebbles,  grains  of  corn,  etc.,  into  their  own,  or  others 
ears.  These  bodies  can  almost  always  be  removed  by  syringing 
with  warm  water;  the  auricle  should  be  firmly  drawn  backward 
and  a  little  upward,  and  the  water  thrown  up  the  floor  of  the 
meatus  with  some  force.  This  almost  invariably  succeeds  if 
persevered  in,  and  is  perfectly  safe. 


gas.  629 

No  other  attempt  at  removal  should  be  made  without  full 
illumination,  and  clear  sight  of  the  object,  which  may  then  be 
removed  by  forceps,  or  a  probe  or  ear  spoon  introduced  behind 
it  and  used  as  a  lever. 

Bodies  similar  to  those  put  into  the  ears  are  also  sometimes 
thrust  up  their  nostrils  by  children.  With  a  good  light,  the  assist- 
ance of  the  ear  mirror,  and  a  little  quickness  and  slight  of  hand, 
they  do  not  often  give  much  trouble.  If  they  cannot  be  extracted 
they  can  sometimes  be  thrust  backward  into  the  throat.  If  left 
they  are  apt  to  set  up  a  more  or  less  violent  inflammation,  some- 
times with  profuse,  ill-smelling  discharge;  indeed  the  presence  of 
such  symptoms  in  a  child  should  excite  suspicion,  and  lead  to 
careful  search  for  some  foreign  body.  I  have  known  a  head  of 
timothy  grass  thus  retained  in  the  nose  for  many  months. 

GAS.     (Asphyxiation  from). 

Persons  not  infrequently  become  asphyxiated  from  breath- 
ing for  hours  an  atmosphere  loaded  with  illuminating  or  natural 
gas.  This  may  occur  either  accidentally  or  intentionally.  Such 
persons  are  generally  found  profoundly  insensible,  breathing 
slowly,  perhaps  stertorously,  with  a  feeble  pulse,  perhaps  no 
pulse  perceptible  at  wrist,  with  pale  or  livid  countenance  and 
exhaling  a  strong  odor  of  the  gas.  There  can  be  no.  doubt  of 
the  advisability  of  blood  letting  in  these  cases,  if  the  blood  can 
be  got  to  flow.  It  relieves  the  strain,  and  gets  rid  of  some  of 
the  gas  with  which  the  blood  is  loaded.  Other  means  of  re- 
suscitation,  sprinkling  water  in  the  face,  holding  ammonia  to 
the  nostrils,  etc.,  together  with  artificial  respiration  should  be 
tried.  Of  course  doors  and  windows  should  be  thrown  wide 
open,  even  in  cold  weather.  The  gravity  of  these  cases  depends 
upon  the  length  of  time  the  patient  has  been  breathing  the 
poisonous  atmosphere;  but  as  in  similar  cases  of  asphyxiation 
by  drowning,  etc.,  we  should  persevere  while  there  is  a  ray  of 
hope,  though  the  directly  poisonous  effects  upon  the  nerve 
centres  makes  them  a  very  fatal  class  of  cases. 


630  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

HEMORRHAGE. 

As  the  various  forms  of  internal  hemorrhage  are  considered 
elsewhere  in  this  work,  we  shall  confine  ourselves  here  to  hemorr- 
hages from  wounds.  Hemorrhage  from  wounds  where  no  consider- 
able artery  is  opened  generally  ceases  spontaneously  in  a  few  mo- 
ments if  freely  exposed  to  the  air,  and  many  of  the  devices  resorted 
to  serve  rather  to  keep  up  the  bleeding  than  otherwise.  The  tem- 
porary control  of  hemorrhage,  which  is  all  we  are  considering 
here,  can  generally  be  accomplished  by  pressure  either  directly 
over  the  wound,  or  over  the  main  artery,  between  it  and  the 
heart.  Direct  pressure  is  generally  sufficient,  especially  when  it 
can  be  made  over  a  bony  surface,  as  on  the  skull.  In  wounds  of 
the  extremities  accompanied  Avith  severe  bleeding,  pressure 
should  be  made  over  the  course  of  the  principal  artery,  above 
the  wound.  This  is  most  efficiently  done  by  means  of  an  elastic 
ligature  or  bandage.  An  india-rubber  cord  or  tube,  or  an  elastic 
suspender,  or  garter  drawn  tightly  round  the  limb,  generally 
suffices.  If  the  blood  is  dark  and  the  now  apparently  increased 
by  pressure  above,  it  is  venous,  remove  all  bandages,  and  rely  on 
direct  pressure.  Avoid  styptics,  especially  cobwebs,  which  from 
the  soot  they  often  contain  may  leave  an  indelible  mark,  like 
a  tattoo -mark. 

HERNIA. 

Hernia,  or  rupture,  as  it  is  commonly  called,  is  a  very  com- 
mon affection.  It  consists  in  the  protrusion,  through  natural  or 
accidental  openings,  of  some  of  the  abdominal  contents.  The 
great  danger  in  these  cases  is  strangulation,  which  is  j>receded  by 
inability  to  return  the  hernial  contents  to  the  abdominal  cavity, 
as  the  patient  has  been  in  the  habit  of  doing,  it  may  be,  for 
many  years.  This  returning,  or  reduction  of  the  hernia,  is  called 
•  taxis,  and  should  be  accomplished  without  force  or  violence.  A 
physician  or  surgeon  who  is  determined  to  accomplish  the  reduc- 
tion if  strength  of  hand  can  do  it,  is  a  dangerous  person. 

In  performing  taxis,  bear  in  mind  the  anatomical  direction 
in  which  the  hernia  must  return,  if  at  all.  Then,  after  gently 
but  persistently  compressing  the  base   of  the  tumor   for  a  few 


HERNIA INJURIES    TO    THE    BRAIX.  631 

minutes,  endeavor  to  return  or  push  it  back,  remembering  that 
the  part  that  was  last  to  come  out  must  be  first  to  go  back. 
Should  one  attempt  of  this  kind  fail,  the  patient  may  be  left  for 
an  hour  or  two  with  ice  applied  to  the  tumor,  and  then  another 
effort  made,  under  ether,  being  prepared,  if  this  fails,  to  proceed 
with  the  necessary  operation;  the  great  danger  in  these  cases 
being  in  delay. 

INJURIES  TO  THE  BRAIN. 

Concussion  or  Compression. — By  concussion  is  meant  a  jar  to 
the  cranial  contents,  a  molecular  disturbance  of  the  brain  sub- 
stance, which  may  lead  to  loss  of  consciousness  and  other  symp- 
toms, varying  in  gravity  from  a  momentary  dizziness  to  those 
which  threaten  to  be  fatal.  Whether  there  can  be  any  such  con- 
dition without  actual  injury  to  brain  substance  or  blood  vessels 
is  a  matter  of  doubt,  and  likely  long  to  remain  so,  as  cases  of 
concussion  pure  and  simple  give  no  opportunity  for  post  mortem 
examination.  Compression,  or  pressure  upon  the  cranial  con- 
tents may  be  immediate  from  depressed  bone  or  hemorrhage;  or 
later  from  inflammatory  products. 

With  the  first  only  are  we  concerned;  the  diagnosis  is  not 
always  easy.  But  if  there  is  fracture  with  evident  depression  of 
bone,  the  accompanying  symptoms  are  due  to  compression.  In 
compression  we  have  generally  contracted  pupil,  small  thready 
pulse,  often  stertorous  breathing,  and  generally  paralysis  (hemi- 
plegia). In  concussion  the  pupils  are  dilated,  or  one  dilated, 
the  other  contracted,  in  but  few  cases  is  consciousness  com- 
pletely abolished,  and  there  is  generally  nausea  and  vomiting. 

In  all  these  cases  of  head  injury  the  patient  should  be  kept 
perfectly  quiet,  in  a  darkened  room,  and  nobody  allowed  to  ap- 
proach him  except  those  that  are  absolutely  necessary.  The 
head  should  be  elevated,  and  ice  or  cold  water  compresses  ap- 
plied. If  the  vital  powers  are  very  much  lowered,  as  indicated 
by  pale  and  cool  surface,  small  and  irregular  pulse,  artificial 
heat  by  means  of  hot  bottles,  water-bags,  etc.,  should  be  applied. 
Stimulants,  if  given  at  all,  should  be  used  with  care  in  small 
doses,  and  at  considerable  intervals.  In  those  cases  which  are 
accompanied  with   great   restlessness,  or  convulsions,  or  severe 


632  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

pain,  morphine  may  be  given  hypoclerniically  with  advantage. 
The  old-fashioned  practice  of  bleeding,  or  administering  an 
active  purgative  in  these  cases,  is  of  doubtful  utility  at  the  best, 
and  may  do  more  harm  than  good.  Above  all,  bear  in  mind 
Percival  Pott's  celebrated  aphorism,  as  true  to-day  as  when  it 
was  first  uttered:  uNo  injury  of  the  head  is  so  slight  as  to  be 
despised,  or  so  grave  as  to  be  despaired  of." 

POISONED  WOUNDS. 

Under  this  head  we  mean  especially  wounds  received  in  the 
dissecting  room,  or  in  making  post-mortem  examinations,  the 
latter  of  which  are  the  more  dangerous.  These  wounds  are  gene- 
rally upon  the  hand  or  fingers;  after  letting  water  run  over  the 
part  for  a  moment,  or  just  rinsing  it  in  water,  apply  to  the  mouth 
and  suck  with  all  the  force  possible,  then  cauterize  thoroughly 
with  nitrate  of  silver,  which  though  of  very  feeble  power  as  a 
caustic,  coagulates  the  albuminous  fluids  in  and  about  the  wound, 
forming  barrier  to  absorption,  and  perhaps  neutralizes  the 
poison  itself.  In  the  absence  of  the  nitrate  any  strong  acid  or 
alkali,  or  tincture  of  iodine,  may  be  used,  or  even  strong  alcohol. 
In  snake-bite,  a  ligature  tied  tightly  between  the  wound  and  the 
heart,  with  strong  suction,  should  be  practiced  at  once,  pending 
the  arrival  of  professional  assistance.  In  bites  from  suspected 
dogs,  Mr.  Youmans,  who  is  certainly  high  authority,  places  great 
reliance  on  the  application  of  nitrate  of  silver. 

POISONING. 

In  cases  of  poisoning  or  suspected  poisoning,  there  are  cer- 
tain general  measures  which  may  be  taken  even  when  the  nature 
of  the  poison  is  unknown,  or  before  a  proper  antidote  can  be 
procured.  Prominent  among  these  is  the  production  of  free 
vomiting  by  any  means  at  hand,  such  as  salt  and  water,  mustard 
and  water,  tickling  the  fauces  with  a  feather,  or  the  finger. 
After  vomiting  has  been  produced  let  the  patient  drink  large 
quantities  of  warm  water,  or  if  there  is  much  pain  and  irritation 
diluent  drinks,  such  as  milk  and  water,  soap  and  water,  flax- 
seed tea  or  the  like  if   procurable.     If   there   is    a   tendency  to 


POISONING SHOCK.  633 

drowsiness  this  should  be  combatted  by  every  means  in  our 
power,  keeping  the  patient  walking  about,  switching  the  surface 
etc.,  etc.  In  poisoning  cases  all  suspicious  powders,  mixtures, 
vials  etc.,  should  be  taken  possession  of,  and  preserved  pending 
the  result,  as  they  may  be  of  the  utmost  importance  later  on.  It 
would  always  be  well  also  to  preserve  the  matter  first  vomited. 
Keep  your  eyes  wide  open,  observe  everything,  and  say  nothing. 

SHOCK. 

This  is  the  sudden  depression  of  the  vital  powers,  brought 
about  by  accident  or  injury-  The  factors  which  enter  into  the 
cause  of  shock  are  various.  Among  them  may  be  mentioned 
extensive  destruction  of  parts,  pain,  when  severe  or  protracted; 
this  is  exemplified  in  the  case  of  extensive  burns;  hemorrhage, 
mental  impressions,  and  direct  assault  upon  nerve  centres. 
Shock,  even  to  a  fatal  degree,  has  been  the  result  of  evil  tidings 
suddenly  communicated,  or  of  blows  upon  the  epigastrium, 
when  no  serious  injury  could  be  recognized. 

The  principal  symptoms  are,  more  or  less,  complete  loss  of 
consciousness,  with  or  without  delirium,  pain,  or  its  complete 
absence  even  when  frightful  mutilation  has  been  sustained. 
Palor  and  coolness  of  surface,  sub -normal  temperature,  weak, 
nickering  pulse,  or  absence  of  pulse  at  wrist,  and,  in  extreme 
cases,  muffled  and  imperfect  heart  sounds,  sighing,  irregular  res- 
piration, cold  sweat,  especially  about  the  brow;  and  when  there 
has  been  much  hemorrhage,  jactitation  and  thirst.  Death  may 
result  in  a  short  time,  or  the  patient  may  recover  even  after  a 
very  severe  and  protracted  attack.  Generally  reaction  begins  in 
two  or  three  hours. 

The  treatment  of  shock  consists  entirely  in  efforts  to  restore 
the  vital  powers,  or  as  it  is  technically  phrased  to  bring  about 
reaction.  Any  hemorrhage  that  is  going  on  must  be  stopped. 
The  patient  placed  in  a  warm  bed  in  the  horizontal  position, 
with  the  head  low.  Sometimes  it  is  advantageous  to  raise  the 
foot  of  the  bed.  External  warmth  should  be  promoted  by  hot 
water  bottles  or  bags;  or  hot  bricks  or  irons,  cart-  being  taken 
not  to  burn  the  patient,  who  is  not  in  a   condition  to  give  warn- 


634  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

ing  when  applications  are  too  hot.  Stimulants  should  be  admin- 
istered in  extreme  cases  by  rectum  or  hypodernrically.  If  given 
by  the  mouth,  care  is  necessary  lest  an  overdose  be  administered, 
as  absorption  as  well  as  other  functions  is  in  abeyance,  and  if 
the  stomach  be  filled  with  alcohol  an  injurious  amount  may  be 
absorbed  when  reaction  comes  on.  Where  great  pain  or  rest- 
lessness is  present,  or  there  has  been  much  hemorrhage,  opium  in 
some  of  its  forms  may  be  freely  given.  As  a  general  rule, 
operations  should  be  postponed  till  reaction  is  established  or  at 
least  well  began;  but  this  rule  does  not  apply  to  cases  of  abdom- 
inal injury  where  operation  may  be  called  for.  In  such  cases 
the  operation  should  be  proceeded  with  as  speedily  as  possible, 
as  the  only  way  of  preventing  a  fatal  result. 

SPRAINS. 

By  a  sprain  is  understood  a  wrenching,  stretching,  or  rupt- 
ure, partial  or  complete  of  the  ligaments  of  a  joint,  or  its  partial 
dislocation.  The  ankle  is  the  joint  that  most  frequently  suffers, 
and  there  are  all  possible  degrees  in  the  severity  of  the  injury. 
Pain  is  generally  severe,  and  somtimes  accompanied  by  nausea  or 
vomiting,  there  is  always  more  or  less  discoloration  (ecchymosis) 
sometimes  quite  extensive.  The  best  immediate  application  is 
hot.  water,  this  should  be  applied  as  hot  as  can  be  borne,  and 
frequently  changed.  This  application  may  be  continued  for 
twelve  or  twenty-four  hours,  after  which  it  is  of  doubtful  util- 
ity, and  should  be  followed  by  a  snug,  smoothly  applied  flannel 
bandage.  If  swelling  and  pain  persist  after  two  or  three  days 
the  joint  should  be  immobilized  by  a  plaster  of  Paris  bandage, 
to  be  retained  two  or  three  weeks,  and  then  reapplied  if  neces- 
sary. When  pain  and  swelling  have  nearly  disappeared,  but 
there  is  still  some  stiffness  and  pain  on  motion,  rubbing  with 
some  anodyne  liniment  may  be  of  use.  A  sprain  often  leaves 
some  weakness,  with  occasional  pain  in  the  joint  for  years. 


CHAPTER    V. 

ANAESTHETICS  AND  THEIR  MODE  OF 
ADHINISTRATION. 


Anoesthetics  are  those  agents  wliicli  are  employed  for  the 
prevention  of  pain,  especially  when  used  in  surgical  practice  and 
during  labor.  They  are  likewise  used  to  produce  relaxation  of 
muscles,  when  needed  in  reducing  dislocations  and  hernia,  or  in 
setting  fractured  bones.  They  may  be  also  resorted  to  in 
making  diagnosis  in  cases  of  obscure  abdominial  tumors  and  in 
supposed  malingering. 

Anaesthesia  may  be  produced  by  benumbing  the  part  to  be 
operated  on  by  means  of  cold,  by  intercepting  nervous  commu- 
nication, and  by  arresting  the  activity  of  the  nervous  centres 
concerned  in  sensation.  They  may  be  local  or  general  in  their 
action  (Horwitz). 

The  Introduction  of  Anaesthetics. — This  great  event  has  cast 
a  wide-spread  influence  upon  the  progress  of  surgery.  In  1842 
Crawford  W.  Long,  of  Georgia,  removed  a  tumor  with  the  pa- 
tient under  the  influence  of  an  anaesthetic.  ~No  further  attempt 
was  made  until  1844,  when  Wells  had  a  tooth  extracted  while 
insensible  with  nitrous  oxide  gas.  Morton,  at  the  suggestion  of 
Dr.  Jackson,  anaesthetized  a  patient  on  October  16th,  1846,  while 
Dr.  J.  C.  Warren  removed  a  tumor  from  the  patient's  neck. 
From  this  time  on,  anaesthesia,  hitherto  a  dream,  now  became  a 
living  reality.  To  Jackson,  Morton  and  Wells,  the  profession  is 
indebted  for  this  great  discovery,  which  is  the  greatest  boon  to 
suffering  humanity. 

There  is  one  sad  event,  however,  connected  with  this  dis- 
covery, and  that  is  the  melancholy  termination  of  the  life  of 
each  of  the  three  men  associated   with  it.     Jackson  died  insane; 


636  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

Morton  died  without  worldly  means;  "Wells  became  a  pauper 
and  was  arrested  in  New  York  city  as  a  criminal  for  throwing 
vitriol.  He  was  sent  to  jail,  and  there  committed  suicide  by 
cutting  his  femoral  artery.  It  is  interesting  to  note  in  this  con- 
nection, that  Sir  Edward  Jenner,  the  discoverer  of  vaccination, 
was  awarded  8225,000  for  his  discovery  by  an  act  of  Parliament, 
while  by  no  act  of  the  United  States  Government  has  anything 
been  done  to  perpetuate  the  memory  of  these  three  men.  The 
physicians  of  Hartford  have  erected  a  statue  to  Wells  (Dennis). 

Important  Anaesthetics. — The  important  anaesthetics  are:  1. 
Ether.  2.  Chloroform.  3.  Nitrous  oxide  gas.  4.  Bichloride  of 
methylene.     5.  Bromide  of  Ethyl. 

Physiological  Actions. — When  the  vapor  of  ether  or  chloro- 
form is  inhaled,  a  sense  of  faucial  irritation  and  of  the  need  of  air 
is*  experienced,  and  more  or  less  cough  is  produced.  The  irrita- 
tation  of  the  fauces  excites  the  flow  of  mucus,  and  the  reflex  act 
of  swallowing.  The  feeling  of  the  need  of  air  causes  the  patient 
to  push  aside  the  inhaler  or  sponge,  and  in  children  may 
lead  to  violent  struggling.  The  irritation  soon  ceases  and  the 
inhalation  then  proceeds  quietly.  The  first  effect  is  a  general 
exhilaration,  the  pulse  increases  in  frequency,  the  respirations 
become  more  rapid,  the  face  flushes,  talking,  laughing,  crying, 
siDging,  and  sometimes  praying  indicate  the  cerebral  intoxication. 
This  stage  of  excitement  varies  in  duration  in  different  individu- 
als. At  this  period,  although  the  patient  can  be  easily  aroused, 
sensibility  to  pain  is  decidedly  diminished.  If  the  inhalation  be 
continued,  the  patient  passes  into  the  condition  of  complete 
insensibility. 

In  women  and  children,  and  males  reduced  by  illness,  the 
production  of  insensibility,  if  the  anaesthetic  be  not  inhaled  too 
rapidly,  takes  place  quietly;  but  if  the  subject  be  a  robust  male, 
in  full  health,  the  stage  of  insensibility  is  preceded  by  a  tetanic 
convulsive  stage,  in  which  the  voluntary  muscular  system  and 
the  respiratory  muscles  become  rigid,  the  breathing  stertorous, 
and  the  face  cyanosed.  If  the  inhalation  of  the  anaesthetic  be 
pushed  still  further,  the  tetanic  rigidity  subsides,  the  cyanosis  dis- 
appears, the  breathing  proceeds  quietly,  and  a  condition  of  com- 
plete muscular  relaxation,  and  of  abolition  of  reflex   movements. 


ANAESTHETICS.  637 

is  established.  When  this  is  accomplished,  the  arm  drops  with- 
out resistance  when  let  fall,  the  conjunctiva  is  insensible  to  irrita- 
tion, the  pupils  do  not  alter  in  size  when  exposed  to  light,  and 
there  is  no  consciousness  of  pain.  The  surface  is  cool,  and  bathed 
with  abundant  perspiration,  the  countenance  is  placid,  the  eyes 
closed,  the  pupils  rather  contracted  than  dilated;  the  respiration 
easy,  but  more  shallow  than  normal;  the  pulse  slower — it  maybe 
feebler,  it  may  be  stronger  than  in  health.  The  functions  of  the 
cerebrum  are  suspended;  only  the  lower  centres,  23residing  over 
respiration  and  circulation,  continue  in  action  (Bartholow). 

Modes  of  Dying  from  Anaesthetic  Vapors.— 1.  By  the  first 
mode,  the  death  is  sudden  and  occurs  very  soon  after  the  inhala- 
tion has  begun,  and  is  ascribed  to  "irritation  of  the  peripheral 
nervous  system,  accumulation  of  carbonic  acid  in  the  blood,  and 
arrest  of  the  action  of  the  heart."  The  chloroform  vapor  seems 
to  paralyze  the  cardiac  ganglia.  This  accident  sometimes  occurs 
in  persons  who  have  previously  taken  the  anaesthetic  without 
unfavorable  symptoms  of  any  kind. 

2.  By  the  second  mode,  death  ensues  in  the  stage  of  rigid- 
ity preceding  complete  muscular  relaxation,  and  is  due  to  tetanic 
fixation  of  the  respiratory  muscles.  In  these  cases  respiration 
ceases  before  the  pulsations  of  the  heart  cease. 

3.  By  paralysis  of  the  respiratory  muscles,  death  ensues 
during  the  stage  of  complete  muscular  relaxation,  and  the  action 
of  the  heart  continues  for  some  seconds,  or  even  minutes,  after 
respiration  has  ceased. 

4.  By  paralysis  of  the  heart.  This  also  occurs  in  the 
course  of  complete  insensibility;  the  motor  ganglia  are  para- 
lyzed, and  the  heart  suddenly  ceases  to  act,  the  respirations  con- 
tinuing for  a  short  time  longer. 

5.  This  mode  of  dying  is  made  up  of  two  factors  :  Deju-es- 
sion  of  the  functions  by  chloroform  narcosis,  and  the  shock  of 
the  accident  or  surgical  operation.  Death  may  ensue  during  the 
inhalation,  or  may  occur  afterward  (Bartholow). 

Conditions  of  the  Organism  Rendering  the  Use  of  Anaesthetics 
Dangerous. — 1.  Experience  has  proved  that  old  drunkards  are 
very  unfavorable  subjects. 


638  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

2.  When  a  tumor  or  abscess  of  the  brain  exists,  it  is  dan- 
gerous to  administer  anaesthetics. 

3.  Very  much  enlarged  tonsils,  swollen  epiglottis,  oedema  of 
the  glottis  are  contraindications. 

4.  Emphysema  and  fatty  heart  are  unfavorable  conditions 
for  an  anaesthetic.  Experience  has  demonstrated  that  those 
reduced  by  illness,  and  the  feeble,  bear  anaesthetics  better  than 
the  healthy  and  robust;  that  children  and  women  are  better  sub- 
jects than  men;  that  anaesthetics  are  safer  when  given  for  opera- 
tions for  disease  than  for  injury. 

5.  Incomplete  anaesthesia  is  a  condition  of  danger.  Many 
accidents  have  occurred  from  trivial  operations — particularly 
extraction  of  teeth — before  complete  insensibility.  In  such  cases 
the  heart,  enfeebled  by  chloroform  narcosis,  is  suddenly  par- 
alyzed by  the  reflex  action  proceeding  from  the  peripheral  injury 
(Bartholow). 

The  chloroform  committee  of  the  Royal  Medical  and  Chir- 
urgical  Society  of  London  formulated  the  following  rules  for  the 
administration  of  anaesthetics: 

1.  Anaesthetics  should  on  no  account  be  given  carelessly  or 
by  the  inexperienced;  and  when  complete  insensibility  is  desired 
the  attention  of  the  administrator  should  be  exclusively  confined 
to  the  duty  he  has  undertaken. 

2.  Under  no  circumstances  is  it  desirable  for  a  person  to 
give  an  anaesthetic  to  himself. 

3.  It  is  not  advisible  to  give  an  anaesthetic  after  a  long  fast 
or  soon  after  a  meal,  the  best  time  for  its  administration  being 
four  or  five  hours  after  food  has  been  taken. 

4.  If  the  patient  is  much  depressed,  there  is  no  objection  to 
his  taking  a  small  quantity  of  brandy,  wine,  or  ammonia  before 
commencing  the  inhalation. 

5.  Provision  for  the  free  admission  of  air  during  the  patient's 
narcotism  is  absolutely  necessary. 

6.  The  recumbent  position  of  the  patient  is  preferable;  the 
prone  position  is  inconvenient  to  the  administrator,  but  entails  no 
extra  danger.  In  the  erect  or  sitting  posture  there  is  danger 
from  syncope.  Sudden  elevation  or  turning  of  the  body  should 
be  avoided. 


ANAESTHETICS.  639 

7.  An  apparatus  is  not  essential  to  safety  if  due  care  be 
taken  in  giving  the  anaesthetic.  Free  admixture  of  air  with  the 
anaesthetic  is  of  the  first  importance,  and,  guaranteeing  this,  any 
apparatus  may  be  employed.  If  lint,  or  a  handkerchief  or  a 
napkin  is  used  it  should  be  folded  as  an  open  cone  or  held  an 
inch  or  an  inch  and  a  half  from  the  face. 

8.  Chloroform  should  invariably  be  given  slowly.  Sudden 
increase  of  strength  of  the  anaesthetic  is  most  dangerous.  Three 
and  a  half  per  cent,  is  the  average  amount,  and  four  and  a  half 
per  cent.,  with  ninety- five  and  a  half  per  cent,  of  atmospheric 
air,  is  the  maximum  of  the  anaesthetic  which  can  be  required, 
given  cautiously  at  first,  the  quantity  within  this  limit  being 
slowly  increased  according  to  the  necessities  of  the  case,  the 
administrator  being  guided  more  by  its  effect  on  the  patient 
than  by  the  amount  exhibited.  Ether  may  be  given  more 
boldly. 

9.  The  administrator  should  watch  the  respiration  of  his 
patient,  and  must  keep  one  hand  frees  for  careful  observation 
of  the  pulse. 

10.  When  patients  hold  their  breath,  more  air  should  be 
admitted;  and  when  the  movement  of  swallowing  is  seen,  it 
should  be  accepted  as  evidence  that  the  anaesthetic  is  stronger 
than  necessary.  On  any  sound  of  stertor  fresh  air  should  be 
admitted. 

11.  The  j)atient  who  appears  likely  to  vomit  while  begin- 
ning to  inhale  the  anaesthetic  must  at  once  be  brought  fully 
under  its  influence;  the  tendency  to  sickness  will  then  cease. 

12.  The  occurrence  during  the  administration  of  an  anaes- 
thetic of  sudden  pallor,  lividity  of  the  patient's  countenance,  or 
sudden  failure  or  flickering  of  the  pulse,  or  feeble  or  shallow 
respirations,  indicates  danger,  and  necessitates  immediate  with- 
drawal of  the  anaesthetic  until  such  symptoms  have  disappeared. 
The  chin  should  be  raised  as  much  as  possible  from  the  sternum, 
and  if  this  movement  fail  to  oj)en  the  larynx,  the  tongue  should 
be  pulled  forward  and  the  head  drawn  back. 

13.  Nelaton  and  Marion  Sims  advise  the  inversion  of  the 
body,  with  the  view  of  throwing  what  blood  there  is  wholly  to 
the  brain,  on  the  theory  that  death  from  chloroform  is,  as  a  rule, 


640  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

clue  to  syncope  or  to  cerebral  anaemia.  In  the  more  threatening 
cases,  commence  instantly  with  artificial  respiration,  whether  the 
respiration  has  failed  alone,  or  the  pulse  and  respiration  together. 
Galvanism  may  be  used  in  addition  to  artificial  respiration,  but 
artificial  respiration  is  on  no  account  to  be  delayed  or  suspended 
in  order  that  galvanism  may  be  tried.  In  extreme  cases,  laryng- 
otomy  may  be  required. 

Few,  if  any,  are  insusceptible  to  the  influence  of  anaesthetics, 
from  two  to  ten  minutes  being  required  to  induce  anaesthesia. 
The  time  varies  according  to  age,  temperament  and  habits.  The 
mixture  of  alcohol  one  part,  chloroform  two  parts,  and  ether 
three  parts,  which  should  be  mixed  fresh  before  use,  should  be 
given  in  the  same  way  as  chloroform  alone,  care  being  taken, 
when  lint  or  a  handkerchief  is  used,  to  prevent  the  too  free 
escape  of  the  vapor.  In  Vienna  the  favorite  mixture  is  three 
parts  of  ether  to  one  of  chloroform.  Billroth  employs  chloroform 
three  parts,  ether  one  part,  and  alcohol  one  part  (Bryant). 

Preparation  of  the  Patient  for  Taking  an  Anaesthetic. — 
Before  giving  ether,  the  kidneys  should  be  interrogated,  and  the 
urine  examined.  If  the  kidneys  are  diseased,  it  may  cause  sup- 
pression of  urine  and  death.  In  operations  upon  the  bladder 
and  urethra  the  shock  of  the  023eration  and  the  effects  of  the  an- 
aesthetic are  very  apt  to  produce  suppression  of  urine. 

If  we  operate  in  the  afternoon  and  the  patient  is  aware  of 
the  operation,  he  should  have  no  food  after  the  morning  meal. 
Always  avoid  solid  food  for  six  or  seven  hours  before  the  time 
for  the  operation.  This  is  to  prevent  vomiting  which  is  liable  to 
follow  the  administration  of  ether.  Solid  particles  of  food  may 
be  drawn  into  the  larynx  and  produce  death.  Vomiting,  as  the 
narcosis  subsides,  is  usual,  and  as  the  insensibility  of  the  glottis 
persists  for  some  time  afterward,  particles  of  food  may  be  lodged 
in  the  chink,  causing  fatal  suffocation.  Several  cases  of  this 
kind  have  been  reported.  There  should  be  nothing  binding 
about  the  patient's  neck  or  waist.  We  should  use  certain  means 
to  anticipate  vomiting.  Before  the  inhalation  is  begun,  it  is 
rjroper  to  administer  an  ounce  or  two  of  whiskey  or  brandy. 
Five  or  six  grains  of  the  bromide  of  sodium  are  often  given 
before  the  operation  to  prevent  vomiting.     But  much    more  im- 


ANAESTHETICS.  641 

portant  is  the  expedient  proposed  by  Bernard,  and  afterward  by 
Nussbauin,  to  premise  a  subcutaneous  injection  of  morphine. 
Bernard  proposed  to  administer  the  morphine  before  giving  the 
anaesthetic.  If  the  morphine  be  given,  there  is  much  less  likely- 
hood  of  vomiting,  and  if  the  patient  does  vomit,  it  is  not  so  ex- 
hausting. When  the  morphine  influence  takes  place,  the  inhala- 
tion will  proceed  quietly  without  the  struggling  and  coughing, 
and  spasmodic  breathing,  which  so  interfere  with  the  administra- 
tion of  anaesthetics,  especially  of  ether.  The  use  of  morphine 
subcutaneously  also  lessens  materially,  if  not  prevents  entirely, 
the  stage  of  rigidity  and  spasm.  The  quantity  of  the  anaesthetic 
required  is  much  less,  and  the  stage  of  insensibility  more  pro- 
longed, when  morphine  is  thus  given. 

Besides  these  advantages,  there  can  be  no  doubt  that  this 
agent  antagonizes  the  paralyzing  action  of  the  anaesthetic  on  the 
cardiac  and  respiratory  centers,  and  prevents  the  subsequent 
shock  due  to  the  administration  of  the  anaesthetic  and  the  per- 
formance of  a  surgical  operation.  Bartholow  proposed  the  use 
of  morphine  and  atropine  combined  as  being  better  than  the 
morphine  alone. 

When  the  anaesthetic  is  about  to  be  administered,  the 
operator  should,  by  a  cheerful  and  confident  manner,  remove  the 
fears  of  the  patient.  None  of  the  paraphernalia  of  the  opera- 
tion to  be  performed  should  be  exhibited  before  the  patient,  and 
no  remarks  should  be  made  in  his  hearing  regarding  his  case, 
the  anaesthetic  sleep,  or  the  surgical  procedure.  Only  the  physi- 
cian having  the  administration  of  the  anaesthetic  in  charge,  and 
the  necessary  assistants,  should  be  present  in  the  apartment.  An 
abundant  supply  of  fresh  air  should  be  insured  to  the  patient, 
and  all  appliances  required  for  resuscitation  should  be  at  hand, 
but  not  ostentatiously  paraded  before  the  patient. 

Inhalers. — The  simplest  apparatus  only  is  required.  Com- 
plicated inhalers  have,  as  frequently  as  a  towel  or  handkerchief, 
been  used  in  fatal  cases  of  chloroform  narcosis.  A  cone  made 
of  stiff  paper,  and  a  towel,  with  a  sponge  or  absorbent  cotton  in 
the  bottom  of  it,  and  large  enough  to  cover  the  nose  and  mouth 
of  the  patient,  is  the  best  form  of  inhaler  for  the  administration 
of  ether.      Dr.   Allis,   of  Philadelphia,   has  devised   an  inhaler 


642  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

which  is  much  commended.  When  ether  is  inhaled,  the  atmos- 
phere is,  as  far  as  possible,  excluded,  in  order  that  the  anaes- 
thetic effect  may  be  quickly  induced.  The  important  point  in 
the  administration  of  chloroform  is  to  secure  such  an  admixture 
of  atmospheric  air  as  that  the  amount  of  chloroform- vapor  shall 
not  exceed  three  and  a  half  per  cent.  If  this  rule  be  regarded, 
the  form  of  inhaler  is  of  little  importance. 

A  cloth  may  be  laid  over  the  mouth  and  nose  and  the  chlor- 
forni  dropped  slowly  on  it.  The  mouth  and  nose  should  be  pro- 
tected from  the  irritant  action  of  the  chloroform  by  inunction 
with  oil  or  vaseline.  Chloroform  applied  to  the  skin  directly 
produces  vesication,  and  this  my  be  followed  by  permanent  dis- 
figurement of  the  face.  A  cone  made  of  a  towel,  having  a  large 
opening  at  the  apex,  and  containing  a  suitable,  very  porous 
sponge,  is  now  probably  more  employed  than  any  other  form  of 
inhaler  for  giving  chloroform.  The  typical  method  for  admin- 
istering it  is  that  of  Snow:  in  a  bag  of  suitable  size  the  vapor 
of  choloroform  is  mixed  with  air  in  the  proper  proportion,  and 
then  given  directly.  In  administering  the  vapor  of  chloro- 
form by  any  of  the  modes  in  use,  it  should  not  be  forgotten  that 
it  has  a  density  and  weight  four  times  those  of  air,  and  that, 
when  a  cloth  is  held  closely  over  the  mouth,  the  air  is  displaced, 
and  the  patient  may  be  breathing  little  more  than  chloroform - 
vapor.  During  the  administration  of  ether,  attention  should  be 
directed  to  the  state  of  the  respiration,  for  arrest  of  the  respira- 
tory movements  is  the  only  source  of  danger.  When  chloroform 
is  being  inhaled,  the  state  of  the  circulation,  as  well  as  of  the 
respiratory  apparatus,  must  be  regarded  (Bartholow). 

Indications  of  Danger  in  Giving  Anaesthetics. — If  the  patient 
becomes  very  much  cyanosed,  let  up  on  the  anaesthetic, 
and  let  him  breathe  some  pure  air  or  oxygen.  If  the  pulse 
becomes  irregular,  let  up  on  the  anaesthetic.  A  rapid  and  feeble 
pulse,  especially  if  irregular,  is  a  very  dangerous  symptom.  If 
the  respirations  become  rapid  and  superficial,  let  up  on  the  anaes- 
thetic. If  the  patient  vomits,  see  to  it  that  all  foreign  particles 
of  food  are  removed.  If  the  secretion  of  mucus  collects  in  the 
throat,  it  should  be  wiped  away  with  a  sponge  on  a  sponge - 
holder. 


ANAESTHETICS.  643 

Means  of  Removing  Dangerous  Symptoms. — If  the  heart  fails, 
suspend  the  patient  by  the  heels.  This  is  to  relieve  the  cerebral 
anaemia.  If  the  respirations  fail,  we  should  have  on  hand  a  pair 
of  forceps  to  grasp  the  tongue  with,  in  case  it  falls  back  against 
the  epiglottis,  and  the  skin  should  be  pinched  over  the  dia- 
phragm to  stimulate  it  to  contraction,  and  the  jaw  should  be 
pulled  forward  to  get  free  ingress  of  air.  The  head  should  be 
only  slightly  raised.  We  should  always  have  a  Faradic  battery 
and  a  few  of  the  little  pearls  of  nitrite  of  amyl  at  hand;  the 
former  is  to  perform  artificial  respiration,  and  the  latter  is  to 
relieve  the  heart  by  dilating  the  blood-vessels,  and  thus  dimin- 
ishing arterial  pressure.  Artificial  warmth  should  be  applied. 
Whiskey  or  brandy  may  be  used  hypodermically.  Strychnine 
and  atropine  are  the  best  respiratory  stimulants,  and  are  effective 
in  ether  narcosis  (A.  A.  Smith  and  Bartholow). 

Choice  of  Anaesthetics. — Ether  is  safer  than  chloroform  in 
prolonged  surgical  operations.  Chloroform  is  more  pleasant  to 
inhale  than  ether,  and  should  be  used  in  operations  about  the 
nose,  throat,  tongue,  or  mouth,  owing  to  the  fact  that  ether  is 
very  irritating  to  the  mucous  membranes.  Chloroform  is  irritat- 
ing to  the  skin,  but  not  to  mucous  membranes.  The  stage  of 
excitement  is  longer  from  ether  than  from  chloroform.  Chloro- 
form is  more  prompt  in  its  effects,  and  the  narcosis  induced  by 
it  more  sustained,  than  is  the  case  with  ether.  The  vapor  of 
chloroform  is  not,  and  the  vapor  of  ether  is,  inflammable,  whence 
it  follows  that  the  former  may  be  alone  admissible  at  night  under 
some  circumstances.  If  the  heart  be  diseased,  ether  is  the  anaes- 
thetic to  be  used.  If  the  kidneys  be  diseased,  chloroform  is  the 
proper  anaesthetic.  Vomiting  and  suppression  of  urine  is  more 
apt  to  follow  ether  than  chloroform  (Bartholow  and  A.  A.  Smith). 
A.  C.  E.  mixture,  composed  of  alcohol  one  part,  chloroform  two 
parts  and  ether  three  parts,  is  useful  when  the  operation  is  to  be 
a  very  long  one.  It  produces  no  cardiac  depression  unless  used 
over  twenty  minutes.  If  a  man  has  renal  disease  and  a  broken 
leg,  the  A.  C.  E.  mixture  is  the  proper  anaesthetic.  An  old 
alcoholic  is  apt  to  have  delirium  tremens  if  he  gets  a  broken  leg, 
or  a  fracture  of  the  skull,  or  any  other  injury.     The  A.  C.  E. 


644  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

mixture  is  the  anaesthetic, to  be  used  in  these  cases.     This  class 
of  patients  do  not  bear  any  form  of  anaesthetic  well. 

After=Effects  of  Anaesthetics. — The  after  nausea  and  vomit- 
ing, which  are  sometimes  most  depressing,  and  occasionally  dan- 
gerous, produced  by  anaesthetics,  may  be  prevented  by  the  hypo- 
dermic injection  of  morphine  and  atropine  before  beginning  the 
administration  of  the  anaesthetic.  After  the  patient  emerges 
from  the  anaesthetic  sleep,  the  above  mentioned  unpleasant  after- 
effects may  be  relieved  by  a  minute  quantity  of  morphine  (ttj  of 
a  grain)  and  atropine  (lib  of  a  grain)  injected  subcutaneously 
(Bartholow). 

After  the  operation,  do  not  wake  the  patient,  but  let  him 
sleep  as  long  as  he  will.  This  lessens  the  liability  to  vomiting. 
After  taking  ether  patients  do  not  want  anything  to  eat  for  some  time 
Give  the  patient  a  cup  of  hot  water  as  soon  as  he  can  take  it  after 
coming  out  from  the  ether.  After  ether  taking  give  milk  or 
beef-tea. 

It  is  necessary  to  surround  the  patient  with  warmth,  as  Dr 
H.  A.  Hare,   quoted   by  Ringer,   has   recently  shown  that  pro 
longed  etherization  considerably  lessens  the   body  temperature 
He  has  reduced  the  temperature  from  8°  to  10°  F.,  and  in  opera 
tions  he  has  seen  a  fall    of    4.4°  F.  in    man.     Probably  other 
anaesthetics    produce    the    same    effect.      Some    surgeons   wrap 
children  in  cotton  wool,  covering  not  only  the  body,  but  also  the 
extremities,  before  giving  the  anaesthetic, 

Anaesthetics  in  Midwifery. — Chloroform  is  to  be  preferred  in 
labor,  because  more  pleasant  to  inhale,  more  prompt  in  action, 
and  without  inflammability.  Experience  has  shown  that  chloro- 
form is  perfectly  safe  in  labor  when  properly  administered. 
When  the  labor  is  of  short  duration,  and  not  excessively  painful, 
anaesthetics  should  not  be  used;  on  the  other  hand,  when  the 
labor  is  protracted  and  the  suffering  great,  they  favor  the  pro- 
gress of  the  case  and  prevent  exhaustion  and  uterine  inertia.  In 
labor,  chloroform  should  not  be  given  until  complete  dilatation 
of  the  os  has  taken  place,  the  head  descending  and  the  pains 
propulsive.  It  should  be  inhaled  only  when  the  pains  come  on, 
and  there  is  no  doubt  that  its  entire  safety  in  obstetric  practice 
is  due  to  the  intermittent  plan  of  administering  it.     To  relieve 


ANAESTHETICS.  645 

the  pain  of  labor,  complete  narcosis  should  not  be  produced,  as 
cessation  of  uterine  contractions  and  loss  of  uterine  retractility 
may  result,  leading  to  a  delay  in  the  delivery,  retention  of  the 
placenta,  and  even  post-partum  hemorrhage.  The  patient  should 
take  a  full  inspiration  of  the  chloroform  vapor  during  the  aura 
of  a  labor  pain,  and  then  bear  down-  About  three  deep  inspira- 
tions are  all  that  she  will  be  able  to  take  during  any  one  pain. 
Toward  the  close  of  the  second  stage  of  labor,  when  the  head 
begins  to  distend  the  external  parts,  the  quantity  of  chloroform 
may  be  somewhat  increased,  but  the  inhalation  should  be  dis- 
continued when  the  occiput  has  passed  under  the  pubic  arch. 
Chloroform  is  said  to  favor  laceration  of  the  cervix  and  peri- 
neum, but  this  is  not  believed. 

Instrumental  or  manual  interference  with  labor  may  render 
complete  anaesthesia  necessary,  or  it  may  be  needed  to  aid  in  the 
relaxation  of  a  rigid  cervix,  or  to  prevent  the  woman  from  bear- 
ing down  when  the  perinaeuin  is  endangered  by  a  too  rapid  de- 
livery. If  puerperal  convulsions  occur  at  any  stage  of  labor, 
the  utility  of  chloroform  is  unquestionable.  If  the  patient  has 
valvular  cardiac  disease,  this  does  not  contra-indicate  anaesthetics 
as  was  formerly  thought.  The  shock,  when  an  anaesthetic  is  not 
used,  is  more  dangerous  than  the  anaesthetic.  Dr.  A.  A.  Smith, 
of  'New  York,  considers  organic  heart  disease  as  a  special  indi- 
cation for  the  use  of  chloroform.  Give  only  enough  to  take 
away  the  acuteness  of  the  pain.  Give  it  during  the  ''aura11  of 
a  pain  for  four  or  five  pains,  and  then  withhold  it  for  a  pain  or 
two,  in  these  cases  of  heart  disease.  When  forceps  or  version 
are  indicated  in  these  heart  cases,  it  is  better  to  use  ether,  because 
it  then  becomes  a  surgical  case,  and  should  be  treated  as  other 
surgical  cases.  Never  use  forceps,  or  perform  version,  or  crani- 
otomy with  the  patient  only  partially  under  the  anaesthetic. 
Finally,  it  is  generally  conceded  that  no  well-authenticated  case 
of  death  from  the  use  of  chloroform  in  labor  has  occurred,  when 
the  administration  was  in  the  hands  of  a  properly  qualified  medi- 
cal man  (Bartholow  and  A.  A.  Smith).  Chloroform  insensi- 
bility may,  with  care,  be  maintained  for  hours  and  even  days. 

In  administering  anaesthetics,  the  attention  should  be  directed 
to  the  state  of  the  jmlse,  the  breathing,  the  conjunctiva,  and  the 


646  A    COMPENDIUM    OF    PRACTICAL     MEDICINE 

pupil.  If  the  pulse  become  quick  and  weak,  or  irregular,  then 
the  inhalation  must  be  withheld.  The  breathing  often  affords 
an  earlier  sign  of  danger  than  the  state  of  the  pulse.  If  the  res- 
pirations become  shallow,  and  gradually  less  frequent,  the  anaes- 
thetic should  be  suspended  for  a  time. 

The  surest  signs  of  safety,  and  the  earliest  of  danger,  are 
afforded  by  the  state  of  the  conjunctiva  and  pupil.  While  irri- 
tation of  the  conjunctiva  causes  reflex  action,  and  is  followed  by 
blinking,  there  is  usually  no  danger.  The  pupil  is  much  con- 
tracted in  the  stages  of  insensibility  when  no  danger  is  to  be  ap- 
prehended; but  on  the  approach  of  peril  from  an  overdose  of  the 
anaesthetic,  the  pupil  dilates. 

It  should  in  every  case  be  made  a  rule  that  no  operative 
measures  of  any  kind  be  allowed  until  the  patient  is  in  the  stage 
of  relaxation.  It  is  important  to  be  able  to  obtain  early  warning 
that  vomiting  during  narcosis  from  anaesthetics  is  about  to  super- 
vene. The  pupil  will,  as  was  pointed  out  by  M.  Budin,  afford  a 
clue.  He  found,  and  my  experience  confirms  his  statement,  that 
when  the  patient  is  about  to  vomit  the  pupils  commence  gradu- 
ally to  dilate.  Efforts  at  swallowing  air  are  initiated  at  this 
time,  and  the  pulse  flags  slightly.  If  now  the  anaesthetic  be  dis- 
continued, the  pupils  widely  dilate,  vomiting  occurs,  and  the 
patient  regains  consciousness  rapidly.  But,  on  the  other  hand, 
if  the  administrator,  aware  of  the  import  of  these  signs,  pushes 
the  anaesthetic,  the  pupils  regain  the  contraction  which  is  normal 
to  the  state  of  relaxation,  and  vomiting  is  obviated,  while  the 
pulse  recovers  its  force.  The  gradual  dilatation  spoken  of  above 
must  not  be  confounded  with  the  sudden  dilatation  which  be- 
tokens grave  danger.  In  this  last  case,  stertor,  shallow  breath- 
ing, and  marked  lessening  of  the  pulse -force  also  occur,  together 
with  cyanosis. 

It  should  be  borne  in  mind  that  operations  on  the  rectum 
and  vagina,  even  when  the  patient  is  quite  insensible,  generally 
cause  noisy  catchy  breathing,  very  much  resembling  stertorous 
breathing,  often  mistaken  for  it,  and  sometimes  thought  to  indi- 
cate that  too  much  of  the  anaesthetic  has  been  inhaled;  but  this 
is  not  the  case.  The  true  state  of  things  can  be  made  out  as 
follows:     The  noisy  breathing  does  not  occur  until  the  rectum 


AN  .ESTHETICS. 


647 


and  vagina  are  manipulated,  and  is  especially  loud  and  noisy 
when  the  finger  or  an  instrument  is  passed  with  any  force  into 
either  orifice. 

Are  there  any  conditions  of  age  or  health  which  forbid  the 
use  of  anaesthetics?     Provided  due  care  be  observed,  it  may  be 
given  to  all  persons,  irrespective  of  their  condition.     It  has  been 
given   in   serious   heart  disease;  in  every  stage  of  phthisis;  in 
Bright's  disease,  cancer,  chronic  bronchitis;  to  patients  almost 
dead  of    exhaustion  from  loss  of  blood;  to  children  of  a  few 
weeks,  and  to  persons  close  upon  a  hundred  years  old.     It  is 
safe  to  say  that  any  person  fit  for  a  severe  operation  is  a  fit  sub- 
ject for  an  anesthetic,  but  no   one  is  so  free  from  danger  that 
care  in  watching  its  effects  can  be  dispensed  with.  .  The  cases 
requiring  the  greatest  vigilance  are  not  the  young  and  delicate, 
for  whom  a  small  close  suffices,  but  the  strong,  who  inhale  deeply, 
and  struggle  much  (Bartholow,  Ringer  and  Bryant).  It  requires 
special   study,  combined  with  practice,  to  administer  anaesthetics 
in  the  proper  manner.     In  a  great  many  operations,  the  skillful 
anaesthetizer  is  of  more  importance  to  the  final  success  of  the  opera- 
tion than  the  operator  himself.     The  experienced  administrator 
takes  a  great  load  and  responsibility  from  the  operator's  mind, 
reduces  death  from  ether  and  chloroform  to  a  minimum,   and 
lessens  the  risks  of  every  operation. 

Nitrous  Oxide  Gas. — Is  not  much  used  now  as  an  anaesthetic. 
It  is  cumbersome  since  it  requires  an  extensive  apparatus.  It  is 
expensive.  It  was  first  used  by  Horace  Wells,  a  dentist  of  Hart- 
ford. It  is  used  at  the  present  day  principally  in  dentistry.  It 
is  not  feasible  for  prolonged  surgical  operations.  It  causes  cya- 
nosis and  the  pulse  becomes  increased  in  force  and  diminished  in 
frequency.  The  patient  will  recover  from  it  in  three  minutes. 
Some  cases  suffer  for  two  or  three  days  after  its  administration 
from  a  disturbance  of  the  nervous  system.  It  may  cause  sleep- 
lessness and  muscular  tremor.  This  gas  is  both  a  pleasant  and 
efficient  anaesthetic,  more  rapid  and  at  the  same  time  more  tran- 
sitory in  its  action  than  either  ether  or  chloroform.  It  is  espe- 
cially adapted  for  the  extraction  of  teeth,  opening  of  abscesses, 
and  similar  minor  operations.  The  amount  necessary  to  produce 
anaesthesia  is  one  to  two  gallons.     It  is  best  administered  from 


648  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

an  India-rubber  bag,  containing  about  eight  gallons  of  the  gas. 

Bichloride  of  Methylene. — Is  similar  to  chloroform  and  was 
first  proposed  as  an  anaesthetic  by  Dr.  B.  W.  Richardson.  It 
produces  its  effects  inore  quickly  and  may  be  used  in  smaller 
quantity  than  chloroform.  It  is  agreeable  to  inhale  and  causes 
no  heart  depression.  It  is  not  used  in  this  country  at  the  present 
day,  but  is  used  in  England  a  great  deal,  esjoecially  by  Spencer 
Wells  and  his  followers,  who  pronounce  its  vapor  to  be  the  best 
known  anaesthetic.  It  does  not  produce  any  gastric  disturbance. 
It  is  considered  more  dangerous  than  chloroform  or  ether. 

Bromide  of  Ethyl. — Is  a  quick  anaesthetic.  The  odor  is  not 
unpleasant,  and  but  little  irritation  of  the  air-passages  is  pro- 
duced. It  is  now  seldom  resorted  to  as  an  anaesthetic.  It  may 
cause  almost  instant  death  by  paralyzing  the  heart.  It  is  a  dan- 
gerous anaesthetic.  Ott  states  that  it  destroys  life  by  a  toxic 
action  on  the  respiratory  centre. 

Chloral  as  an  Anaesthetic. — Dr.  Bouchut  recommends  the  use 
of  chloral  as  an  anaesthetic  for  children.  He  gives  one  dose,  not 
exceeding  forty-five  grains,  in  children  under  three  years  of  age. 
In  half  an  hour  the  patient  is  asleep,  and  in  an  hour  insensible. 
The  anaesthesia  lasts  from  three  to  six  hours  and  is  followed  1  > y 
no  unpleasant  consequences.  Thirty  grains  may  be  given  with- 
out danger,  Bouchut  says,  to  children  between  two  and  five  years 
of  age  (Bryant). 

Bonwell's  Method  of  Introducing  Anaesthesia. — Take  a  full  in- 
spiration and  then  let  the  expiration  go  by  installments.  This 
must  be  done  slowly  and  regularly.  By  this  method,  the  sensi- 
bility will  be  benumbed  so  that  the  rectum  may  be  examined. 
It  may  be  used  in  opening  an  abscess  and  in  pulling  teeth.  It 
will  relieve  many  cases  of  insomnia.  This  method  depends 
largely  on  the  influence  of  the  mind  over  the  body. 

Deaths  from  the  Different  Anaesthetics. — Dr.  Lyman  has  col- 
lected thirty- seven  fatal  cases  from  the  inhalation  of  ether,  three 
hundred  and  ninety- three,  from  the  administration  of  choloro- 
form,  nine  from  the  employment  of  bichloride  of  methylene,  four 
which  maybe  attributed  to  nitrous  oxide  gas,  and  several  from 
the  use  of  ethyl  bromide. 


CLINICAL  INDEX. 


ABORTION — Chloride  of  gold  will  avert  the  tendency  to  habitual  abortion.  Corn- 
utine,  an  alkaloid  of  ergot,  will  increase  uterine  action  when  required  in  abor- 
tion. Opium  will  check  uterine  action.  Ergot  will  restrain  the  hemorrhage. 
All  drugs  are  dangerous  to  life  when  used  in  sufficient  quantity  to  produce  an 
abortion. 

ABSCESS  — Belladonna,  internally,  will  prevent  the  formation  of  abscesses  in 
the  neck  and  elsewhere,  and  after  the  onset  of  suppuration  will  check  the 
pain  and  inflammation.  Belladonna  plaster  will  subdue  the  inflammation. 
Nitrate  of  Silver  solution  in  nitrous  ether  applied  over  the  inflamed  area  and 
adjacent  region  will  abort  the  inflammation.  Ointments  or  powder  of  iodol 
and  iodoform  are  valuable.  Counter  =  Irritation,  byblisters  or  tinclure  of  iodine 
around  or  adjacent  to  the  abscess,  is  of  great  utility.  Caustic  potash  or  soda 
is  sometimes  used  to  open  abscesses  with  the  intention  of  preventing  scarring. 
Sulphides,  half  grain  every  few  hours,  will  abort  abscess  or  hasten  the  forma- 
tion and  extrusion  of  the  pus.  Ether  may  be  Used  as  a  spray  to  produce  local 
anaesthesia  for  opening  abscesses.  Poultices  will  check  the  formation  of  pus 
or  assist  in  maturation.  Fomentations,  with  a  solution  of  20  grs  carbonate 
of  ammonium  to  one  pint  of  boiling  water,  are  of  great  utility  in  threatened 
mammary  abscess.  Iodine  solution  may  be  injected  into  the  cavities  of  large 
abscesses  after  evacuation.  Carbolic  acid,  boracic  acid  and  permanganate  of 
potassium  solutions  may  be  used  for  washing  out  cavities  of  abscesses. 

ACIDITY. — Mineral  acids  may  be  given  shortly  before  meals  for  acid  pyrosis,  and 
after  meals  for  alkaline  pyrosis.  Sulphurous  acid  may  be  given  for  acid  fer- 
•mentation  with  vomiting  of  pasty  matter.  Acid  wine  may  be  taken  during 
meals.  Alkalies  may  be  given  after  meals  for  immediate  relief,  but  are  only 
palliative.  Nux  vomica  in  two  or  three  drop  doses  just  before  meals  is  effi- 
cient in  acidity  of  pregnancy.  Gray  powder  in  half  grain  doses  three  times 
daily  may  be  given  for  acidity  with  clayey  stools.  Carbolic  acid  will  stop  the 
fermentation  and  eructation. 

ACNE. — Phosphorus  may  be  given  in  acne  indurata.  Sulphur  may  be  used  inter- 
nally. Sulphur,  dr.  j.,  glycerine,  oz.  j.,  rose  water,  Oss  ,  applied  to  the  face, 
as  a  lotion,  twice  daily  will  be  effective  in  acne  of  young  women  with  disor- 
dered menstrution.  Corrosive  sublimate,  one  part;  alcohol,  enough  to  dis- 
solve it;  water,  100  parts.  A  teaspoonful  of  this  may  be  added  to  a  quarter 
of  a  pint  of  water  and  the  face  sponged  with  it  night  and  morning.  Arsenic 
(Fowler's  sol.)  in  two  drop  doses,  three  times  daily,  will  prevent  bromic  acne. 
Bismuth  may  be  dusted  on  the  face  when  there  are  heat  and  redness.  Sub- 
limbed  sulphur  applied  as  a  powder  to  the  eruption  is  one  of  the  best  applica- 
tions. Alkaline  lotions,  as  liquor  potassa?  dr.  j.  and  aqua?  rosa?  oz.  iv.,  applied 
with  a  soft  sponge  twice  daily  are  useful  when  the  skin  is  greasy  and  sebaceous 
follicles  full.     Hot  sponging  is  effective  in  acne  indurata. 

ADYNAMIA. — Alcohol  in  the  form  of  whisky,  brandy  or  wine  of  good  body,  in  tea- 
spoonful  doses  after  meals  is  most  useful.  Give  brandy  when  bowels  are  re- 
laxed, and  whisky  when  there  is  constipation.  Aliment,  as  beef,  milk  and  cod- 
liver  oil.  Bitters,  as  quassia,  gentian  and  calumba.  Quinine  in  gr.  ss.-gr.  j. 
doses  t.  i.  d.  Iron  may  be  given  to  stimulate  digestion  and  promote  blood  for- 
mation. Nux  vomica  tincture  in  doses  of  three  to  five  drops,  t.  i.  d.  is  bene- 
ficial. 

AFTER-PAINS. — Chloral  in  large  doses  is  effective.  Camphor  (ten  grains)  in  a 
mixture  with  a  little  morphine  (one-eighth  of  a  grain)  is  a  very  efficacious 
remedy,  florphine  (gr.  %)  and  atropine  (gr.  Tiu),  hypodermically,  will  give 
prompt  relief. 

AGUE. — Quinine  is  by  far  the  best  remedy  we  possess  for  ague.  In  mild  forms 
small  doses  several  times  daily  and  in   malignant  forms  large  doses  continued 


650  A    COMPENDIUM    OF    PRACTICAL     MEDICHSTE. 

for  a  long  time.     Arsenic,  in  three  to  ten  drop  doses  of  Fowler's  solution  is  the 
best  remedy  except  quinine.     Nitro=gIycerine  may  avert  the  cold  stage. 

ALBUMINURIA. — The  milk  cure,  especially  butter-milk.  Basham's  mixture,  tea 
spoonful  t.  i.  d.,  is  of  service  in  anaemic  patients.  Arsenic,  three  drops  t.  i.  d. 
of  Fowler's  sol.  after  meals  for  kidney  changes.  Gallic  acid  has  the  power  to 
restrain  the  waste  of  albumen  in  cases  of  acute  albuminuria.  It  may  be  given 
as  follows:  Acidi  gallici,  dr.  j.,  acidi  sulphurici  dil.  dr.  ss.,  tinct.  lupuli  dr.  j., 
infus.  lupuli  oz.  vj.,  m.  Sig.:  A  tablespoonful  three  times  daily.  Gold  and 
sodium  chloride,  in  the  dose  of  TV-23o  grain,  t.  i.  d.  is  of  the  highest  utility  in 
chronic  albuminuria.  Nitro=glycerine  (T^  gr.)  daily,  increased  gradually  will 
relieve  the  high  arterial  tension  in  acute  and  chronic  Bright's  disease.  Digitalis 
may  be  used  when  the  quantity  of  urine  is  much  diminished.  Pilocarpine  may 
be  used  cautiously. 

ALCOHOLISM. — Bromides  in  drachm  doses  may  be  given  for  the  "horrors." 
Arsenic,  in  drop  doses  before  breakfast  for  the  morning  vomiting.  Cimicifuga 
for  the  dyspepsia  of  drunkards.  Morphine  with  tonics  before  meals  for  pain, 
nausea  and  want  of  appetite.  Capiscum  and  nux  vomica  may  be  given  as 
stomachic  tonics. 

AMAUROSIS. — Strychnine  will  cure  amaurosis  of  a  functional  kind,  from  lead,  to- 
bacco and  alcohol. 

AMENORRHQ3A. — Aconite  tincture  in  drop-doses  every  half  hour,  for  sudden  sup- 
pression of  menses.  Aloes  and  iron  may  be  given  when  due  to  anaemia  and 
torpor.  Apiol  in  a  dose  of  fifteen  grains  daily  for  five  days  before  the  expected 
period,  is  effective  in  amenorrhoea  due  to  anaemia  and  torpor  of  the  ovaries  and 
uterus.  Hydropiper  in  thirty  minim  doses  of  the  fluid  extract  four  times  daily 
for  a  week  before  the  menses  ought  to  appear.  Chloride  of  gold  and  sodium 
in  Jo  Sr-  dose  thrice  daily  when  dependent  on  torpor  of  the  ovaries.  Hot  mus- 
tard sitz.  baths  for  five  days  before  the  period.  Potassium  permanganate,  one 
grain  thrice  daily  for  a  week  before  the  period.  It  may  restore  it  after  two 
years  delav. 

AN/EMIA. — Cold  sponging  is  useful  in  anaemia.  Hypophosphites  of  lime  and  soda, 
a  grain  thrice  daily.  Phosphate  of  lime,  a  grain  thrice  daily,  in  anaemia  of 
growing  persons,  and  of  women  weakened  by  rapid  child-bearing  or  excessive 
menstruation.  Trinitrin  in  doses  of  one  minim  of  the  one  per  cent,  solution 
gradually  increased  to  many  will  cure  many  cases  of  anaemia.  Quinine  in 
doses  of  one  grain  three  times  daily,  for  badly  fed,  pale  town-Hvers.  Iron  in 
all  forms  of  anaemia.  Arsenic  is  effective  in  proper  doses.  Wines  with  good 
body.     Galvanism  to  stimulate  the  functions  of  organic  life. 

ANESTHESIA.— Galvanism  to  the  spine  and  affected  parts.  The  electric  brush 
is  useful  in  anaesthesia.  Strychnine,  hypodermically,  ^  gr.  daily  increased 
gradually. 

ANEURISM. — Potassium  iodide,  in  full  doses  relieves  the  pain  and  promotes  co- 
agulation of  the  blood  in  the  sac.  A  low  diet  with  absolute  repose  in  the 
recumbent  posture.  Barium  chloride  one-fifth  of  a  grain,  three  times  a  day  for 
four  weeks,  then  two-fifths  may  be  given  for  months.  Aconite  slows  the  cir- 
culation and  thus  facilitates  coagulation  in  the  sac.  Ergot,  especially  ergotin 
hypodermically  has  been  very  effective.  Galvano=puncture  has  but  rarely  suc- 
ceeded. 

ANGINA  PECTORIS. — Arsenic  (Fowler's  solution)  in  full  doses,  is  very  efficient  to 
prevent  attacks  given  during  the  intervals.  Amyl  nitrite,  two  to  five  drops 
by  inhalation  affords  prompt  relief  in  cases  characterized  by  elevated  arterial 
tension.  Nitro=glycerine  one  minim  of  a  one  per  cent.  sol.  at  stated  intervals 
is  superior  to  amyl.  Ether,  in  small  quantity  by  inhalation,  may  abort  a  mild 
attack,  hypodermically  in  the  worst  cases.  Nitrite  of  sodium,  one  grain  sev- 
eral times  daily.     Morphia,  gr.  \,  may  be  given   hypodermically  for   the   pain. 

ANTHRAX.— Carbolic  acid  applied  locally. 

APHONIA. — Atropine  (T-J-„  gr.)  morning  and  evening  will  remove  aphonia  due  to 
fatigue  of  vocal  cords.'  It  will  also  cure  hysterical  aphonia.  Nitric  acid  in  ten 
minim  doses  of  the  dilute,  is  effective  in  the  hoarseness  of  singers  and  when 
aphonia  is  reflex.  Electricity  (galvanism)  usually  cures  when  due  to  paresis  of 
the  vocal  cord. 

APHTH/E.— Bismuth  subnitrate  may  be  applied  to  ulcers.  Potassium  chlorate 
(gr.  x.  to  oz.  j.)  mayjbe  used. locally.     Iodoform  dusted  on  is  an   excellent  topi- 


CLINICAL    INDEX.  651 

cal  application.  Quinine  in  tonic  doses  (gr.  ss.  togr.  j.)  is  highly  useful.  Car= 
bolic  acid  (pure)  may  be  applied  to  the  ulcers,  as  an  anaesthetic  and  alterant. 
Alum  may  be  applied  dry  a  few  times  a  day  to  aphthous  ulcers  which  will  not 
heal.     Borax  with  honey,  or  as  glycerine  of  borax  may  be  applied  to  ulcer. 

APOPLEXY.— Croton  oil  in  one-third  minim  dose,  may  be  given  every  hour  as  a 
purgative.  Venesection  or  leeches,  when  the  blood  pressure  is  high  and  hem- 
orrhage threatened  or  proceeding. 

ASCA.RIDES  — Quassia,  an  infusion,  as  a  rectal  injection,  is  one  of  the  most  ef- 
fective agents  for  the  destruction  of  thread  worms.  Carbolic  acid  is  an  efficient 
but  unsafe  parasiticide  when  injected  into  the  rectum.  Iron,  ten  drops  of  the 
syrup  of  the  iodide,  three  times  daily  by  the  stomach  to  prevent  reproduction 
and  dr.  j.  of  the  tinct.  to  Oj.  of  water  by  rectal  injection.  Santonin  in  dose  of 
five  grains  for  adult  at  night  with  or  without  calomel  and  a  laxative  in  the 
morning. 

ASCITES. — Copaiba  resin  may  be  used  as  in  the  following:  Res.  copaibae  dr.  iij., alco- 
hol dr.  v.,  spirit  chloroformi  dr.  j.,  mucil.  acacise  oz.  ij.,  aqua?  ad.  oz.  xij. — M. 
Sig.:  A  tablespooniul  t.  i.  d.  Pilocarpine  very  serviceable  when  given  to  pro- 
duce free  diaphoresis.  Jalap  (compound  powder)  in  teaspoonful  doses  taken  in 
the  early  morning.  Elaterium  in  dose  of  gr.  TVgr.  i,  must  be  given  cautiously. 
Milk  diet  or  dry  diet  will  aid  remedies.  * 

ASTHMA. — Oxygen,  pure  or  diluted  by  inhalation.  Amyl  nitrite  four  or  five 
drops  by  inhalation.  Nitro=glycerine  (gr.  T^)  by  the  stomach.  Arsenic  one 
drop  three  times  daily  to  prevent.  Alum  ten  grains  powdered  and  placed  on 
the  tongue  is  said  to  arrest  a  paroxysm.  Bromides,  in  spasmodic  asthma,  may 
be  given  as  follows:  Potassii  bromidi  oz.  j.,  potassii  iodidi  oz.  ss.,  aqua; 
oz.  iv. — M.  Sig-.:  A  teaspoonful  in  water  every  half  hour  or  hour.  Chloral  in 
twenty  grain  doses  may  arrest  the  paroxysm  but  danger  of  the  chloral  habit. 
Chloroform  by  inhalation  relieves.  Ether  by  inhalation  is  safer  than  chloro- 
form. Atropine  gr.  ^  at  bed  time  may  prevent  paroxysm.  Morphine  (gr.  I -) 
and  atropine  (gr.  TJ^)  hypodermically  are  the  best  agents  to  cut  short  a  parox- 
vsm.  Potassium  iodide  in  full  doses  succeeds  remarkably  in  some  cases. 
Quinine  may  be  given  during  the  intervals  in  grain  doses  thrice  daily.  Strych= 
nine  used  persistently  may  lessen  the  number  of  attacks.  Galvanization  of  the 
pneumogastric  and  cervical  spmpathetic  relieves  the  spasmodic  difficulty  of 
breathing  and  sometimes  effects  a  cure,  and  faradization  of  the  chest  muscles 
has  lately  been  reported  successful  in  effecting  a  cure.  Coffee,  a  very  strong 
infusion,  is  often  useful  in  a  paroxysm.  Lobelia  tincture  in  ten  drop  doses 
every  ten  minutes  till  dyspnoea  gives  way.  Stramonium,  gr.  xx.  of  the  dried 
leaves  may  be  smoked.     Tobacco  smoked  sometimes  gives  relief. 

BALDNESS.— Pilocarpine  may  be  used  locally  in  the  following  formula:  Extracti 
pilocarpin  oz.  j.,  tincture  cantharidis  oz.  ss.,  linimenti  saponis  oz.  iss. — M. 
Sig.:     To  be  applied  to  scalp  daily. 

BED=SORES  — Alcohol  in  form  of  brandy  to  harden  skin  of  parts  exposed  to  pres- 
sure. Alum  with  tinct.  of  camphor  and  whites  of  eggs  is  a  good  topical  appli- 
cation. Resorcin  in  form  of  powder  may  be  dusted  on.  Copaiba  and  castor 
oil  equal  parts,  locally.  Naphthol  as  an  ointment  with  vaseline  is  said  to  be 
the  most  efficient  of  all.  Iodoform  dusted  over  sores.  Charcoal  sprinkled  over 
the  black  slough  which  is  then  covered  with  a  poultice.  Glycerine  rubbed  over 
the  part  exposed  to  pressure  after  washing  morning  and  evening  is  one  of  the 
best  preventives  of  bed-sores.  Silver  nitrate  gr.  xx.  to  oz.  j.  painted  on  the 
unbroken  skin  as  soon  as  it  becomes  red  to  prevent  bed-sores. 

BILIOUSNESS.— Mineral  acids  before  meals  in  acid  indigestion.  Hydrochloric 
acid  and  pepsin  after  meals  in  atonic  dyspepsia.  Sodium  phosphate  in  tea- 
spoonful doses  thrice  daily  for  a  long  time.  Calomel  and  blue  pill  in  small 
quantity  as  laxative  merely.  Ammonium  chloride  in  five  grain  doses  three 
times  daily.     Tincture  of  nux  vomica,   gtt.  v.,  t.  i.  d.  for  three  weeks. 

BITES. — Ammonia,  weak  solutions,  in  bites  of  insects  to  neutralize  the  formic 
acid.  The  strong  aqua  ammonia  should  be  at  once  applied  to  the  bite  of  ven  = 
omous  serpents  and  of  rabid  animals.  Potassium  permanganate,  a  strong- 
solution  applied  locally.     Alcohol  stimulants  internally. 

BLADDER,  CATARRH  OF. -Alkalies  after  meals,  when  the  urine  is  acid.  Ben  = 
zoate  of  ammonia  in  gr.  v.  to  gr.  xx.  thrice  daily  may  be  given  when  the  urine 
is  alkaline  and  loaded  with  phosphates.  Copaiba,  cubebs  and  juniper  are  use- 
ful.   Cantharides,  tinct.  gtt.  iij.  to  gtt.  v.  very  useful. 


652  A    COMPENDIUM    OF    PEACTICAL     MEDICINE. 

BLADDER,  IRRITABILITY  OF.— Belladonna  tinct.  in  ten  minim  doses  until  phys- 
iological effects.  Alkalies  when  urine  is  acid.  Benzoate  of  ammonia  when 
urine  is  alkaline.  Tinct.  cantharides  sometimes  succeeds  in  irritable  bladder 
of  women. 

BOILS. — Arsenic,  Fowler's  solution,  in  three  drop  doses  after  meals  for  a  long- 
time when  there  is  a  succession  of  boils.  Nitrate  of  silver  gr.  xx.-xxx,  dis- 
solved in  nitrous  ether,  and  painted  on  early  will  abort  boils.  Sulphide  of 
calcium  half  grain  three  times  daily  will  hasten  maturation  and  prevent  the 
formation  of  fresh  boils.  ISIo  use  in  the  boils  of  diabetes.  Collodion  may  be 
applied  in  the  papular  or  pustular  stage.  Belladonna  with  glycerine  locally  to 
allay  pain.  Counter=irritation  by  blisters  or  iodine  around  the  boil.  Menthol 
forty  per  cent,  solution  locally.  Poultices  assist  maturation  and  allay  pain. 
They  may  be  smeared  over  with  belladonna  or  opium. 

BRAIN,  DISEASES  OF.— Bromide  of  potassium  in  gr.  xxx.  doses  at  bed-hour, 
when  over-taxed  from  study,  or  over-application  to  business.  Phosphorus 
jo  to  gV  grain  thrice  daily  for  several  months  in  cerebral  softening  and  over- 
taxation. 

BREASTS,  INFLAMMATION  OF  —Belladonna,  especially  as  liniment  to  check 
secretion  of  milk  when  inflammation  is  imminent.  When  inflammation  has 
set  in,  continuous  application  of  belladonna  for  twenty-hours  often  arrests  it. 
It  is  also  useful  when  an  abscess  has  formed.     Digitalis  as  an  infusion  locally. 

BREATH,  FOUL. — Camphor  is  a  common  ingredient  of  tooth  powder  and  is  a  cor- 
rective of  foul  breath.  Chlorine-water  properly  diluted.  Carbolic  acid  in 
dilute  solution  as  a  mouth-wash  and  by  the  stomach.  Potassium  permanganate 
gr.  ij.  to  oz.  j.  of  rose-water  as  a  mouth-wash.  Tinct.  of  benzoin  internally  and 
as  mouth-wash. 

BRIOHT'S  DISEASE.— Milk=cure  especially  an  exclusive  skim-milk  diet,  or  a  diet 
composed  largely  of  milk,  has  been  very  successful.  Water  and  large  draughts 
of  weak  alkaline  waters.  Bitartrate  of  potassaj  as  lemonade,  drunk  freely  as 
a  diuretic.  Digitalis  the  infusion  for  the  dropsy.  Potassium  iodide  in  the 
chronic  cases.  Iron  to  relieve  the  anaemia.  Pilocarpus  highly  useful  in  many 
cases  of  uraemia.  NitrO'glycerine  has  proved  highly  useful  when  there  is  in- 
creased vascular  tension.  Cod=Iiver  oil  in  the  chronic.  Tannin  in  chronic 
Bright's  to  lessen  albumen. 

BRONCHITIS. — Aconite  tinct.  in  small  doses  frequently  in  the  acute  form.  Car= 
bonate  of  ammonia  in  gr.  v.  doses  every  three  hours  if  the  secretion  is  viscid. 
Morphine  or  Dover's  powder  with  quinine  may  abort  an  acute  attack  if  given 
early.  Squills,  the  compound  syrup  with  paregoric  is  useful.  Terebene  may 
be  given  for  the  cough.  Cod=liver  oil  may  be  given  in  the  chronic  form.  Iron 
as  a  tonic.  Strychnine  is  the  best  remedy  to  check  the  reflex  vomiting.  Acids 
to  lessen  the  secretion  in  the  chronic.  Tar,  two  grains  in  pill  every  three  or 
four  hours  in  chronic  paroxysmal  winter  cough.  Wine  of  ipecac  used  as  a 
spray  to  the  pharynx  is  invaluable  in  many  cases  of  bronchial  asthma  and 
winter  cough. 

BRUISES. — Capsicum,  a  strong  tincture  applied  with  gum  is  said  to  act  like  a 
charm  on  discolored  bruises.  Hamamelis  applied  on  lint  or  cotton-wool.  Sul= 
phurous  acid  a  solution  constantly  applied. 

BUBO. — Iodine  applied  to  produce  vesication  round  a  bubo  relieves  the  inflamma- 
tion.    Nitric  acid  may  be  applied  to  indolent  and  broken  bubo. 

BURNS  AND  SCALDS.— Carbolic  acid,  a  one  per  cent,  solution  on  lint  frequently 
renewed  relieves  pain.  Cocaine  as  a  lotion  painted  on  scalds  relieves  the  pain. 
Collodion  painted  over  slight  burns  subdues  inflammation.  Lime  in  the  form 
of  lime-water  combined  with  oil,  enjoys  a  high  reputation.  Carbonate  of  soda 
in  saturated  sol.  to  relieve  pain.  Boracic  acid  most  useful  in  Mr.  Lister's 
hands.  Carbonate  of  lead  and  linseed  oil,  white  lead  paint,  is  an  excellent  ap- 
plication to  burns. 

CALCULI,  BILIARY. — Aliment,  as  starches,  sweets,  and  especially  fats  should  be 
avoided.  Alkaline  mineral  waters  are  highly  useful.  Sodium  phosphate,  dr.  j. 
t.  i.  d.  for  three  months.  Turpentine  and  ether  equal  parts,  gtt.  x.  t.  i.  d.  for 
the  solution  and  cure  of  biliary  calculi. 

CALCULI,  RENAL. — Nitric  acid  very  dilute  as  an  injection  for  phosphatic  calculi. 
Alkalies  to  dissolves  uric  acid  calculi.  Alkaline  mineral  waters  as  vichy, 
Bethesda,  etc. 


CLINICAL    INDEX.  653 

CANCER. — Arsenic  relieves  the  pain  and  retards  the  growth  of  cancer  of  the 
stomach  and  also  of  epithelioma.  Bismuth  relieves  the  vomiting  in  cancer  of 
the  stomach.  Carbolic  acid,  pure,  as  an  anaesthetic  before  applying  caustics. 
Arsenious  acid,  pure,  may  be  used  to  set  up  active  inflammation  in  epithelioma. 
Carbonic  acid  may  be  injected  up  the  vagina  in  cancer  of  the  uterus  to  relieve 
the  pain.  Chloral  in  ten  grain  doses  t.  i.  d.  has  relieved  most  severe  pain  of 
cancer.  Chloroform  as  a  vapor  to  raw,  painful  surface.  Conium  may  be  ap- 
plied as  poultice  to  ease  pain.  Glycerine  of  carbolic  acid  and  glycerine  of 
tannin  combined  checks  the  discharge  and  stench  of  uterine  cancer.  Iodoform 
applied  locally  relieves  the  pain  of  cancerous  sores,  florphia  dissolved  in 
glycerine  and  spread  on  lint,  is  very  useful  where  there  is  much  pain.  Opium 
is  also  used  in  cancer  of  the  stomach.  Poultices  of  starch  applied  cold  soothe 
open  cancers.  Warm  enemata  relieve  the  pain  and  straining  in  intestinal 
cancer. 

CANCRUM  ORIS. — Arsenic  in  medicinal  doses  useful.  Nitric  acid  applied  to  the 
surface. 

CANKERY  TASTE. — Podophyllin  small  doses  fo  grain  night  and  morning.  Pur= 
gatives  as  mercury  and  podophyllin,  are  best.  Water,  half  a  glass  of  pure 
cold,  daily,  half  hour  before  breakfast. 

CARBUNCLE. — Arnica  as  an  ointment  on  plaster.  Belladonna  with  equal  part  of 
glycerine  as  a  local  application  to  allay  pain.  Carbolic  acid  and  glycerine  1  to 
4  on  lint  to  sinuses.  Iodine  applied  round  the  carbuncle  reduces  inflammation. 
Menthol,  ten  to  fifty  per  cent,  in  ether  or  alcohol,  painted  on  several  times 
daily.  Opium,  an  extract  of  the  consistence  of  treacle  applied  three  or  four 
times  a  day. 

CARIES. — Phosphate  and  carbonate  of  lime  to  furnish  needed  materials.  Cod= 
liver  oil  to  promote  constructive  metamorphosis. 

CATARRH,  ACUTE— COMilON  COLD.— Aconite  tinct.  and  belladonna  tinct., 
equal  parts,  two  drops  of  the  mixture  every  half  hour  for  six  or  eight  hours 
and  then  every  two  hours.  Quinine  gr.  xv.  and  morphine  g-r.  ss.  may  at  the 
outset,  abort  an  attack.  Dover's  powder  in  full  dose  of  gr.  x-xv.  at  the  incep- 
tion may  arrest  the  attack.  Iodide  of  potassium  gr.  v  ,  tartar  emetic  gr.  ss., 
syrup  of  orange  peel  oz.  j.,  water  oz.  iij.— M.  Sig.:  Teaspoonful  doses  hourly 
for  children.  Warm  foot=bath  before  going  to  bed.  Turkish  bath  is  useful  in 
chronic  catarrh.  Carbolic  acid  is  of  great  value  by  inhalation  of  vapor  and 
spray. 

CATARRH,  CHRONIC  NASAL.— Alum  in  powder,  may  be  insufflated.  Iodoform 
and  tannin  may  also  be  applied  by  insufflation.  Iodine  in  vapor  may  be  in- 
haled. Ethyl  iodide  five  to  twenty  drops  put  on  a  handkerchief  inhaled  every 
three  hours.  Sanguinaria  ten  drops  of  the  tincture  t.  i.  d.,  and  the  local  ap- 
plication of  the  powder.     Cubeb  in  powder  by  insufflation. 

CATCH  IN  THE  BREATH.— Cold  sponging  night  and  morning  will  improve  or 
even  cure  this  curious  complaint  in  infants. 

CHANCRE. — Eucalyptol  with  iodoform  may  be  applied  to  both  kinds  of  sores. 
Iodoform  may  be  dusted  over  soft  chancres.  Iodol  dusted  over  sore  is  effective. 
Nitric  acid  applied  by  means  of  a  glass  rod  or  pine  stick  to  the  chancre  is  one 
of  the  most  valuable  caustics.  Acid  nitrate  of  mercury  is  the  most  efficient 
escharotic  for  the  destruction  of  chancre  which  we  possess.  Carbolic  acid  may 
be  applied  pure  in  mild  cases.  Chlorate  of  potassium  in  powder  is  al.so  an  ex- 
cellent local  application.     Iodide  of  iron  internally  is  valuable. 

CHANGE  OF  LIFE. — Aetata  is  one  of  the  most  useful  remedies  for  many  of  the  dis- 
tressing symptoms  occurring  at  the  change  of  life.  Ammonia  in  the  form  of 
Raspail's  sedative  lotion  to  be  applied  to  the  painful  part  of  the  head  in  the 
headaches  of  this  period.  Bromide  of  potassium  in  gr.  xx.-xxx.  doses  at  bed- 
time, for  the  despondency  with  sleeplessness  and  irritability  often  also  with 
heats,  flushings  and  perspirations.  Calabar  bean  for  the  flatulence  of  this 
period.  Change  of  air  and  scene  where  other  treatment  fails.  Eucalyptol  for 
various  symptoms  as  palpitations,  flushings  and  flatulence.  Iron  the  tincture 
of  the  chloride  gtt  xv.  t.  i.  d.  in  fluttering  of  the  heart  with  fullness  of  the 
head,  heat  and  weight  on  the  vertex,  frequent  flushings  and  hot  and  cold  per- 
spirations. Nux  vomica  tinct.  gtt.  ij.  and  opium  tinct.  gtt.  ij.  combined  t.  i.  d. 
are  most  useful. 

CHAPS. — Collodion  is  sometimes  used  but  for  chapped  hands  and  lips  glycerine  of 
starch,  arnica  cerate    or  eau     de   cologne   and    glycerine  better.     Compound 


654  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

tinct.  of  benzoin  and  glycerine,  equal  parts,  is  the  best  remedy  for  chapped 
hands  and  lips  and  fissured  nipples.  Sulphurous  acid  and  glycerine,  equal 
parts,  combined  are  most  useful  for  chapped  nipples.  Vaseline  and  petroleum 
are  effective. 

CHEST  PAINS. — Iodine,  as  an  ointment,  in  muscular  pains  of  the  chest.  Bella= 
donna  is  better  when  the  pain  is  in  the  skin. 

CHILBLAINS. — Sulphurous  acid  is  an  efficient  application  to  chilblains,  applied 
as  follows:  Acidi  sulphurosi  dr.  iij.,  glycerine  dr.  j.,  aquas  oz.  iss.— M. 
Benzoin  tincture  applied  locally  is  the  best.  Turpentine  is  efficient.  Balsam  of 
peru  in  ointment  for  broken  chilblains.  Capsicum  tinct.  painted  over  un- 
broken chilblains.  Iodine  tinct.  or  ointment  is  better  painted  over' the  part. 
Carbolic  acid  may  be  used  as  follows:  Acidi  carbol.  dr.  j.,  tinct,  iodi  dr.  ij., 
aciditannici   dr.  ij,  cerat.  simplicis  oz.  iv. — M.     Sig. :     Ointment. 

CHLOROSIS—  Arsenic,  gtt.  iij.  of  Fowler's  sol.  t.  i.  d.  after  meals.  Hypophos= 
phites  of  lime  or  soda  may  be  given  in  grain  doses,  t.  i.  d.  for  some  time.  Iron 
reduced  gr.  v.,  t.  i.  d.  gives  excellent  results.  Iron  may  be  given  with  man= 
ganese  or  arsenic  or  with  aloes  if  constipation  exists.  Water  of  iron-  spring 
most  beneficial.  Massage  with  inunctions  of  oil.  Nux  vomica  may  be  com- 
bined with  iron.  Pepsin  and  pancreatin  aid  digestion.  Galvanism  and 
faradism  to  the  central  nervous  system. 

CHOKING. — Bromide  of  potassium  gr.  iij. -v.  t.  i.  d.  to  a  child  six  years  old,  which, 
from  the  time  of  his  birth,  can  swallow  solids  with  ease,  yet  is  choked  every 
time  he  tries  to  drink. 

CHOLERA,  ASIATICA.— Morphia,  gr.  x/%-\,  hypodermically,  of  the  greatest  value 
even  in  the  stage  of  collapse.  Mercury  in  form  of  gray  powder,  gr.  \  hourly  is 
of  the  greatest  service  in  infantile  cholera.  A  starch  injection  with  a  minute 
quantity  of  laudanum  assist  the  gray  powder.  Arsenic,  Fowler's  sol.  with 
opium  of  service.  Camphor  gtt.  iv.-vj.  of  the  strong  spirit,  every  ten  minutes 
at  first  then  hourly.  Chloral  combined  with  morphine  as  follows:  Chloral 
hydratis  dr.  iij..  morph.  sulph.  gr.  iv.,  aqua;  laur-cerasi  oz.  j. — M.  Sig.:  Fif- 
teen to  thirty  minims.  Chloroform  a  few  drops  frequently  to  stop  vomiting. 
Calomel,  minute  doses  (gr.  2V)  every  hour  will  sometimes  stop  vomiting.  AI= 
cohol  in  form  of  iced  brandy  to  stop  vomiting.  Acetate  of  lead  with  opium  and 
camphor  as  follows:  Plumbi  acetat.  grs.  xxiv.,  pulv.  opii  grs.  xij.,  pulv.  cam- 
phors dr  ss.,  sacch.  alb.  q.  s.,  Ft.  pulv.  no.  xij.  Sig.:  One  powder  every  hour. 
Chlorodyne  very  effective. 

CHOLERA  flORBUS.— Horphine  and  atropine  (gr.  i  and  gr.  1-120)  hypodermically 
is  the  most  efficient  remedy.  Chloral  with  morphine  if  cramps  occur.  Carbolic 
acid  and  bismuth  as  follows:  Acidi  carbolici  grs.  iv.,  bismuthi  subnitrat. 
dr.  ij.,  mucil.  acaciae  oz.  j.,  aqua?  menth.  pip.  oz.  iij. — M.  Sig.:  A  tablespoon- 
ful  every  three  hours. 

CHOLERA  INFANTUM.— Carbolic  acid  is  very  effective.  Bismuth  subnitrate,  gr- 
iij.  every  two  hours.  Calomel  in  minute  doses  arrests  vomiting.  Oxide  of  zinc 
given  in  the  following  formula:  Bismuthi  subnitrat  dr.  iss.,  pepsinae  sacch. 
dr.  ss.,  zinci  oxidi  grs.  vj-grs.  xij. — M.  Ft.  pulv.  no.  xij.  Sig.:  One  powder 
every  four  to  six  hours.     Brandy  is  serviceable. 

CHORDEE.— Camphor,  ten  to  twenty  grains  very  successful.  Potassium  bromide 
dr.  j.,  every  four  hours.  Cantharides  tinct.  one  drop  thrice  daily.  Aconite 
tinct  one  drop  each  hour.  Morphine  gr.  £  and  atropine  gr.  1-150,  hypoder- 
mically will  most  certainly  relieve.  Tartar  emetic  will  relieve  if  carried  to 
nausea.     Tobacco  wine  a  few  drops  at  bed-hour. 

CHOREA.— Cold  effusions  and  cold  bath.  Cod=liver  oil  when  the  nutrition  is  poor. 
Iron  may  be  given  for  the  anaemia.  Arsenic,  Fowler's  sol.  gtt.  iij.  to  x.  t.  i.  d. 
very  successful.  Chloroform  inhalation  t.  i.  d.  in  severe  cases.  Strychnine  in 
increasing  doses  until  stiffness  of  the  muscles  of  the  neck  and  spasmodic  jerk- 
ings.  Hyoscyamus  gr.  1-50  daily.  Morphine  in  large  doses.  Chloral  at  night  is 
highly  useful.  Conium  is  said  to  be  good.  Sulphate  of  zinc  pushed  to  nausea. 
Galvanism  to  the  spine. 

CIRRHOSIS. — Iodide  of  sodium  or  ammonium  in  small  doses  t.  i.  d.  before  meals 
in  first  stage.  Phosphate  of  sodium,  dr.  j.,  t.  i.  d.  for  a  long  time.  Gold  and 
sodium  chloride  in  doses  of  gr.  1-10-1-20  t.  i.  d.  seem  to  have  curative  power  if 
given  in  time.  Arsenic,  Fowler's  sol.  gtt.  v.  t.  i.  d.  retards  or  arrests  the  over- 
growth of  connective  tissue. 


CLINICAL    IXDEX.  655 

COLD=FEET. — Sponging  with  vinegar  and  water  or  hot  and  cold  water  alternately. 
Ice  to  spine.     Strychinia  gr.  1-60  t.  i.  d.  to  promote  capillary  circulation. 

COLIC. — For  the  flatulent  colic  of  infants  no  remedy  is  better  than  mistura  as- 
afoetidaj  which  may  be  given  in  teaspoonful  doses.  Chloroform  a  few  drops 
frequently  useful  in  flatulent  colic  and  in  hepatic.  Ether  internally  and  by 
inhalation.  Camphor,  a  few  drops  of  the  saturated  tinct.  frequently.  Morphine 
and  atropine  hypodermically  the  most  prompt  and  successful.  Hot  fomenta= 
tions  in  all  kinds  of  colic. 

COLICA  PICTONUM.— Sulphuric  acid  diluted  gtt.  x.  t.  i.  d.  riagnesium  sulphate 
to  overcome  constipation.  Morphine  and  atropine  for  pain.  Iodides  and  bro= 
mides  in  proper  doses  to  cause  excretion  of  lead. 

COLIC,  HEPATIC— Morphine  and  atropine  hypodermically  for  the  pain.  Phos- 
phate of  soda  dr.  j.  doses  t.  i.  d.  for  a  long  time  to  dissolve  the  calculi  and 
prevent  the  formation  of  others. 

CONDYLOMATA.— Calomel  dusted  over.  Nitric  acid  dilute  solution  as  a  wash. 
Iodol  dusted  over.  Iodoform  powder  applied  freely.  Carbolic  acid  undiluted 
applied  to  the  part. 

CONJUNCTIVITIS.— Calomel  dusted  over  the  membrane.  Bismuth  in  powder  ap- 
plied directly.  Ergot  fluid  extract,  applied  undiluted,  very  effective.  Castor 
oil,  a  drop  in  eye,  to  allay  pain.  Yellow  oxide  of  mercury  gr.  viij.-x.  to  oz.  j. 
of  vaseline  is  a  most  efficient  remedy  for  granular  lids.  Zinc  sulphate  in  the 
following  formula  is  one  of  the  best  remedies:  Zinci  sulph.  gr.  ij.-iv.,  mor- 
phine sulph.  grs.  ij.-iv.,  atropine  sulph.  gr.  ss.,  aqua?  rosas  oz.  j. — M.  Sig.: 
One  drop  in  the  eye  t.  i.  d. 

CONSTIPATION. — Aliment  as  unbolted  flour,  corn-meal  bread,  fruits  and  vegeta- 
bles. Cascara  sagrada  in  ten  to  fifteen  minim  doses  t.  i  d.  of  the  liquid  ex- 
tract. Arsenic  and  nux  vomica  may  be  given.  Faradizations  of  the  intestines. 
Aloes  with  iron  good  in  chronic  cases.  Saline  mineral  waters  are  effective. 
Podophyllum  and  the  rhubarb  and  soda  mixture  very  efficacious.  Compound 
licorice  powder  in  milk  for  children.  Tobacco,  a  smoke  after  breakfast  some- 
times efficient  in  habitual  constipation.  Enemata  to  unload  the  bowel,  but 
habitually  used  is  harmful. 

CONVALESCENCE. — Alcohol  before  or  at  meals  in  form  of  whisky  or  brandy. 
Fats,  as  cod-liver  oil.  Bitter  tonics  as  gentian,  colomba,  etc.  Lime  water  is 
useful.     Pepsin  and  pancreatine  are  of  service  after  meals. 

CONVULSIONS.— Ice  should  be  applied  to  the  head.  Morphine  gr.  %,  hypoder- 
mically in  uremic  or  puerperal.  Chloroform  and  ether  by  inhalation.  Choloral 
gr.  v.  for  children.  Bromide  of  potassium  in  all  forms.  Warm  bath  for  in- 
fants and  children. 

CORNS. — For  the  cure  of  corns  no  application  is  so  certain,  prompt  and  efficient 
as  liquor  potassae.  It  should  be  applied  by  means  of  a  pine-wood  splinter  to 
the  summit  of  the  corn  and  the  tissue  softened  by  it  scraped  off.  By  successive 
applications  the  callosity  is  removed  without  pain. 

COUGH. — Paregoric  in  teaspoonful  doses  every  three  hours  to  a  child  eight  years 
old.  Cod-liver  oil  in  chronic  coughs.  Creasote  in  winter  coughs.  Glycerine 
and  lemon  juice  are  effective. 

CROUP. — Ipecac  the  syrup,  in  teaspoonful  doses  every  half  hour  until  vomiting  is 
produced.  Alum  dr.  j.  in  honey  or  syrup  every  fifteen  minutes  until  vomiting 
is  produced,  flercury  subsulphate  in  grs.  ij.-v.  is  the  most  efficient  emetic  in 
croup.  Quinine  in  large  doses  is  highly  useful.  Carbolic  acid  in  solution  as  a 
spray. 

CYSTITIS. — Alkalies  to  render  urine  neutral.  Cantharides  one  drop  of  the  tinct. 
t  i.  d.  Laudanum  and  starch  injected  into  the  rectum  relieves  the  pain. 
Pereira,  dr.  ij.-iij.  of  the  liquid  extract  every  three  or  four  hours  for  chronic 
cystitis. 

DANDRUFF. — Borax  saturated  sol.  for  sponging  the  head  several  times  daily. 

DELIRIUM  TREMENS.— Acohol  may  be  of  great  service.  Potassium  bromide  in 
dr.  j.  doses  for  the   "horrors."     Chloroform   by   inhalation   to  procure   sleep. 

DIABETES. — All  saccharine  and  starchy  foods  must  be  excluded.  The  milk=cure 
has  succeeded  remarkably  in  some  cases.  Butter=milk  may  be  better.  Alka= 
line  mineral  waters  are  of  great  value.  Codeine  restrains  the  waste  of  sugar. 
Gold  and  sodium  chloride  is  a  promising  remedy. 


656  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

DIABETES    INSIPIDUS.— Ergot  in  large   doses  is  the   best    remedy.     Dry  diet. 

Iodide  of  potassium  has  cured  cases  of  syphilitic  origin. 
DIARRHOEA.— Bismuth  subnitrate  in  dr.  ss.  doses  t.   i.   d.     Chalk=mixture  with 

opium  in  diarrhoea  of  children.  Calomel  in  small  doses.  Castor  oil  in  the 
early  stage  to  carry  away  the  irritant.  Camphor  with  or  without  opium  for 
summer  diarrhoea. 

DROPSY. — Digitalis  infusion  in  tablespoonful  doses  t.  i.  d.  Saline  purgatives  in 
general  dropsy.  Iodide  of  potassium  in  some  cases  of  Bright's  disease.  Dry 
diet  and  milk=cure.  Nitro=glycerine  in  gradually  increasing  doses  in  cases  of 
high  vascular  tension. 

DYSENTERY. — Salol  is  highly  efficient  in  arresting  intestinal  fermentation. 
Fowler's  sol.  with  opium. 

DYSMENORRHCEA.— Hot  sitz=bath  two  or  three  times  daily.  Aconite  and  pul= 
satilla  for  the  congestive  form.  Amyl  nitrite  by  inhalation,  affords  relief 
quickly.  Gelsemium  and  apiol  give  relief  in  the  neuralgic  form.  Ergot  may 
give  relief.     Morphine  and  atropine  give  prompt  relief. 

DYSPEPSIA. — Milk=cure.  Pepsin,  ingluvin  and  pancreatine  assist  digestion  in 
atonic  dyspepsia.  Muriatic  acid  after  meals.  Alkalies  may  be  given  after 
meals.  Simple  bitters  may  be  gi/en  with  acids.  Fowler's  sol.  drop  doses,  re- 
lieve irritative  dyspepsia.  Nux  vomica  and  wild  cherry  useful  stomachic 
tonics.     Acohol  in  the  form  of  wine  in  small  quantity  before  meals. 

EAR=ACHE.— Morphina;  sulphatis  grs.  iv.,  aqua;  destil.  oz.  j.— M.  Sig.:  Fill  the 
external  meatus  with  the  solution.  Cocaine,  four  per  cent,  solution,  one  drop 
in  the  ear  is  the  most  effective  remedy.  Water  as  hot  as  can  be  borne,  fill  the 
external  meatus.     Counter=irritation  by   blister  behind  the  ear  often  relieves. 

ECLAF1PSIA. — Morphine  subcutaneously  in  uremic  form.  Chloroform  by  inhala- 
tion. Chloral  grs.  xx.  every  two  hours.  Potassium  bromide  in  dr.  ss.  doses 
every  two  hours.  Pilocarpine  in  small  dose  must  be  watched.  Veratrum 
viride  dr.  ss.  of  the  fluid  extract  every  fifteen  minutes  until  nausea  or  vomiting 
ensue. 

ECTHYHA. — Quinia  in  full  doses  often  effects  a  cure.  Cod=liver  oil  internally 
and  externally.     Iodoform,  iodol  and  naphthol  useful  topically. 

ECZEMA. — Arsenic,  Fowler's  sol.  gtt.  iij.-v.  t  i.  d.  after  meals  in  chronic  form. 
Bismuth  subnitrate  as  a  dusting  powder  to  surface.  Salicylate  in  powder  freely 
to  eruption.  Tannin  in  powder  dusted  over.  Boracic  acid  mixed  with  starch 
as  a  dusting  powder.  Atropine  internally  in  acute  cases.  Electricity  (galvan- 
ism) in  chronic  cases.  Iodoform  and  vaseline  in  dry  stage.  Milk  diet  exclu- 
sively. Lime  water  and  glycerine  equal  parts  locally.  Oxide  of  zinc  ointment 
sometimes  beneficial. 

EMPYEHA. — Carbolic  acid,  a  weak  sol.  to  be  injected  after  evacuation.  Iodine 
solution  to  be  injected  after  tapping  to  prevent  reaccumulation  of  pus. 
Chlorine  solution  for  washing  out  the  cavity. 

ENDOCARDITIS.— Quinine,  a  20  to  40  grain  dose  at  the  onset  to  check  the  inflam- 
mation. Morphine  gr.  %  to  gr.  y2,  hypodermically,  will  sometimes  abort  ser- 
ous inflammation.  Salicylic  acid  may  be  given  in  the  rheumatic  form.  The 
potassium  salts  liquefy  the  exudation. 

ENDOMETRITIS.— Undiluted  carbolic  acid  is  an  efficient  application  to  ulcers  of 
the  cervix  uteri,  chronic  endo  cervicitis  and  endo=metritis.  It  may  be  ap- 
plied undiluted  without  risk  to  the  mucous  membrane  of  the  uterine  cavity  on 
the  cotton-wrapped  probe,  after  preliminary  dilatation  of  the  canal.  There  is 
probably  no  better  means  of  treating  uterine  catarrh.  Iodoform  and  tannin 
applied  locally.  Chronic  acid  (grs.  xv.  to  dr.  j.  of  hot  water)  has  been  injected 
into  the  uterine  cavity  with  success. 

ENERGY,  LACK  OF.— The  Turkish  bath,  like  sea-air  and  sea-bathing,  is  a  true 
tonic  in  this  condition. 

EPIDIDYMITIS. — The  oleates  of  mercury  and  morphia  ten  to  thirty  drops  are  suf- 
ficient for  one  application.  It  should  be  applied  twice  daily  for  five  days,  then 
at. night  only  for  five  days,  and  afterwards  every  other  day  until  a  cure  is  ob- 
tained. 

EPILEPSY.— Potassium  bromide  grs.  xv.-xxx.  t.  i.  d.  for  the  diurnal  variety. 
Chloral  full  dose  at  bed-time  may  prevent  nocturnal  attacks.  Iron  to  prevent 
anaemia.     Amyl  nitrite  inhaled  when  the  aura  is  felt  may  prevent  the    seizure. 


CLINICAL    INDEX.  657 

Nitro-glycerine  may  prevent  an  attack  if  given  in  time.     Nitrite  of  sodium  in 

grs.  xx.  doses  t.  i.  d. 
EPISTAXIS. — Aconite  tinct.  in  small  and  frequent  doses  check   nose-bleed  in  chil- 
dren and  plethoric  people.     Alum  in  powder  insufflated  or  a   solution   injected. 
Cocaine  four  per  cent.  sol.  applied  locally  to  nasal  mucous  membrane.    Tannin 
in  solution  locally    applied.     Compression   of  the   facial    artery      Spinal  hot 
water  bag  and  a  hot  foot-bath.     Ergot  in  grs.    ij.-v.,   hypodermically,   to   con- 
tract blood-vessels. 
EPITMELIOriA. — Carbolic  acid   applied   undiluted   to  the   cancerous   sore   and   a 
syringeful  of  a  five  per  cent.  sol.    injected   daily   beneath   the  new   formation. 
Salicylic  acid  (pure)  may  be  applied  in  powder.     Boracic  acid   finely   levigated 
applied  in  powder.     Dried  sulphate  of   zinc   may  be  dusted   over   the    affected 
surface.     Chloride  of  zinc  one  part  and   flour   four   parts   may   be  dusted  over 
the  surface.     Potassium  chlorate  (powdered)   is   thickly    applied  over  the  sore, 
and  is  said  to  allay  pain  and  remove  fetor. 
ERUCTATIONS,  OFFENSIVE.— Mineral  acids  to  correct  the  oxaluria  on  which  the 

eructations  depend. 
ERYSIPELAS,— Aconite  tinct.   one  drop  hourly   until   fever  is  reduced  in  facial 
erysipelas.     Belladonna  tinct.    five  drops    every   two   hours  along   with     the 
aconite.     This  has  a  real  curative  power.     Quinine  in  full  doses.     Tinct.  chlor- 
ide  of  iron  in  large  doses.     Carbolic  acid  (one  per  cent,  sol.)  applied  to   surface 
frequently  on  lint.     Iodine  tinct.  paint  affected  surface  and   surrounding   skin 
to  prevent  spreading.     Nitrate  of  silver  eighty   grains   to   dr.    iv.    of   distilled 
water,  to  be  applied  two  or  three    to  the  inflamed  surface   and  two  inches  be- 
yond. 
ERYTHEMA. — Bismuth  subnitrate  dusted  over  surface  allays  irritation.     Hydro- 
chloric acid  diluted  gtt.  x.  internally  t.  i.  d.     Zinc,  alum  and  lead   as   lotions. 
Quinine  in  tonic  doses  for  some  time. 
EXOPHTHALMIC  GOITRE.— Iron  for  the  existing  anaemia.    Digitalis  good  in  some 
cases.     Ergot  of  service  to  raise  arterial  tension  and  slow  the   heart.     Galvan- 
ism in  uncomplicated  cases  is  decidedly  curative. 
FA1NTINGS. — Cold  water  sprinkled  on  the  face.  Ammonia  to  the  nostrils.  Brandy 

for  feeble  heart.  * 

FEET,  FETOR  OF.— Calicylic  acid  in  powder  freely  dusted  over  the  feet  and  stock- 
ing- is  very  effective.     Sodium  bicarbonate  a   saturated   solution  locally.     Po- 
tassium permanganate  in  solution  will  remove  fetor  temporarily. 
FELON. — Nitrate  of  silver  a  strong  solution  in  nitrous  ether  applied   over  the  part 

may  abort  it.     Carbolic  acid  to  benumb  the  surface  during  incision. 
FEVER.  -  Cold=baths.     Tinct.  aconite,  one  drop,  tinct.  belladonna  two  drops  every 
hour  until  fever  is  reduced.     Antipyrine  grs.    v.   every   two  hours  until  three 
doses  have  been  taken.     Quinine  in  large  doses.     Phenacetine  in  grs.  v.  doses. 
FISSURE    OF    THE    ANUS.— Forcible    dilatation    of     the    sphincter    under    an 
anaesthetic.     Iodoform  dusted  well  over  the  fissure.     Cocaine   to   allay   irrita- 
bility.    Hydrastis  the  fluid  extract  applied  undiluted.     Bromide  of   potassium 
in  five  parts  of  glycerine  locally. 
FISSURE  OF  THE  NIPPLES.— Collodion  applied  to  close  fissure.     Lime  water  as 
a  lotion.   A  solution  of  iron  subsulphate  and  glycerine  applied  with  a  brush  to 
fissure.     Tannin  in  powder  to  part.     Tinct.  of  benzoin  with  glycerine. 
FLATULENCE. — Avoid  sugar,  starchy  food   and  tea.    Asafoetida  one  drachm  of 
the  tinct.  to  oz.  iv.  of  water,  a  tablespoonful  for   adults.     Bismuth  and   char- 
coal equal  parts,   ten-grain   doses.     Chloroform    in   drop   doses   every   fifteen 
minutes.     A  tumbler  of  hot  water  between  meals.     Camphor  as  follows:  Aqua? 
camphorae  oz.  iij.,  tinct.  lavendulae  comp.    oz.    j. — M.     Sig.:     A   tablespoonful 
every  hour.     Turpentine  gtt.  iij. -v.  on  lump  of  sugar. 
FLUSHING  HEATS.— Nitrite  of  amyl   £  of  a  drop  in  five  drops  of   rectified  spirit 
t.  i.  d.     Nux  vomica  tinct.  and  tinct.  of  opium,  equal   parts,   four  drops  t.  i.  d. 
Bromide  of  potassium  fifteen  grains  t.  i.  d. 
FRECKLES. — Biborate  of  soda,  a  saturated  solution,  is  a  safe  and  often  successful 
lotion.     The  following   lotion   is    useful:     Potassi    carbonatis    dr.    iij.,    sodii 
chloridi  dr.  ij.,  aquae  rosae  oz.  viij.,  aquae  aurantii   flor.    oz.  ij. — M.     Sig.:     Lo- 
tion. 

GALL-STONES.— (See  Biliary  Calculi). 


658  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

GANGRENE. — Antiseptics,  as  carbolic  acid,  salicylic  acid,  resorcin,  salol,  iodoform 
and  thymol  are  most  effective. 

GASTRALGIA. — Arsenic  one  or  two  drops  t.  i.  d.  of  Fowler's  solution,  is  the  most 
generally  effective  of  all  remedies.  Chloroform  two  to  five  minims  dropped  on 
sugar  and  swallowed  will  relieve.  Alum  is  useful  in  the  cases  with  acidity  and 
pyrosis.  Injections  of  water  under  the  skin  over  the  epigastrium  affords  much 
relief.  Bismuth,  creasote  and  glycerine  are  useful.  Nux  vomica  may  remove 
the  morbid  state  on  which  the  pain  depends.  Morphine  hypodermically  s^.ops 
the  pain  at  once.     Galvanism  has  been  successful.  Diet  is  of  great  importance. 

GASTRIC  CATARRH.— Arsenic  is  the  most  important  remedy.  The  milk  cure  is  ef- 
fective. The  bitters,  as  calumba,  gentian,  nux  vomica  and  cinchona  infusion 
are  useful.     Bismuth  and  alum  are  of  service. 

GASTRIC  ULCER. — Bismuth  allays  pain  and  arrests  vomiting.  Fowler's  solution 
in  drop  doses  lessens  pain  and  vomiting,  riorphine  and  atropine  arrest  pain 
and  vomiting,  even  in  very  minute  quantity.  Milk-cure  may  be  tried.  Rectal 
alimentation  may  be  necessary.  Silver  nitrate  in  solution  promotes  healing 
and  relieves  pain. 

GLEET. — Blisters  to  the  perinaeum  are  very  beneficial.  Iron  when  the  subject  is 
anaemic.  Turpentine,  juniper  and  cantharides  tinct.  may  be  tried.  Bismuth 
half  an  ounce,  glycerine  half  ounce  and  water  three  ounces,  as  an  injec- 
tion t.  i.  d. 

GOITRE. — Electrolysis  has  succeeded  in  some  cases.    Red  iodide  of  mercury  oint= 

ment  rubbed  in,  in  the  sunshine.  Tinct.  iodine  injected  into  the  gland  applied 
locally.     Iodide  of  potassium  in  ten  grain  doses  internally. 

GONORRHOEA. — Avoid  all  alcoholic  drinks.  Alkalies  to  render  urine  neutral. 
Aconite  tinct.  one  drop  each  hour  in  acute  stage.  Cantharides  drop  doses 
t.  i.  d.  Bismuth  with  fluid  ext.  of  hydrastis  is  one  of  the  best  injections. 
Chloride  of  zinc  two  grains  to  a  pint  of  water  injected  hourly  often  removes 
the  disease  in  twenty-four  to  forty-eight  hours.  Zinc  sulphate  two  grains  to  an 
ounce  of  water  injected  three  to  six  times  daily. 

GUMS,  AFFECTIONS  OF.— Glycerite  of  tannin  for  spongy  and  bleeding  gums. 
Alum  for  the  same  condition  as  above.  Carbolic  acid  when  fetor  is  present. 
Benzoin  tinct.  may  be  applied  to  the  gums. 

H^EflATEMESIS. — Iron  subsulphate  and  pernitrate  solutions,  one  or  two  drops, 
well  diluted  with  ice-water  and  frequently.  Alum  especially  useful  in  passive. 
Lead  acetate  may  be  used  in  all  conditions.  Ergot  may  be  used  in  doses  of  half- 
fluid  drachm.  Ice  to  be  sucked  and  small  pieces  to  be  swallowed.  Tannin 
may  be  used  in  solution.     Turpentine  in  five  to  ten  drop  doses  frequently. 

H/EMATURIA._ — Camphor  two  to  five  grains  when  bloody  urine  is  due  to  drugs. 
Cannabias  indica  is  said  to  relieve  this  condition.  Ergot  may  be  given  by  the 
stomach.  Gallic  acid  is  one  of  the  most  useful  remedies.  Quinine  is  effective 
in  malarial  haematuria.     Turpentine  in  very  small  doses. 

H/EMOPTYSIS. — Common  salt  half  teaspoonful  taken  dry  and  repeated  till  nausea 
is  induced.  Digitalis  infusion  in  large  doses  useful.  Ergot  thirty  to  forty 
minims  overy  two  or  three  hours.  Ice  to  be  sucked.  Morphia  in  small  doses 
hypodermically.  Gallic  acid  and  ergot  bjr  the  stomach.  Spinal  hot  water  bag 
to  cervical  and  upper  vertebrae. 

H/EflORRHAGE,  CEREBRAL.— Venesection  or  leeches  when  blood  pressure  is 
high  and  haemorrhage  threatened  or  proceeding.  Purgatives  may  be  given. 
Frgotine,  hypodermically,  in  two  to  five  grain  doses. 

H/EflORRHAGE,  INTESTINAL — Ice  should  be  applied  to  the  abdomen.  Frgotine 
two  to  five  grains  subcutaneously.  Opium  (laudanum)  in  doses  of  thirty 
minims  to  quiet  intestinal  movements.  Turpentine  in  small  doses  frequently. 
Sulphuric  acid  diluted  in  ten  drop  doses.  Tannic  acid  in  solution  and  other 
astringents. 

H/EMORRHAGE,  UTERINE.— Ergot,  fluid  extract,  in  teaspoonful  doses.  Ipecac 
carried  to  nausea  is  highly  effective.  Turpentine  one  drachm  every  three 
hours.  MonsePs  solution  diluted,  injected.  Tincture  opium  in  one  drachm 
dose  with  brandy.  Ice  or  hot  water  in  uterine  cavity.  Acid  sulphuric  diluted, 
small  doses  frequently. 

H/EnORRHOIDS. — Nitric  acid  half  to  one  ounce  in  half  pint  of  water,  as  a  lotion 
to  bleeding  piles.  Bromide  potassium  one  part  to  five  parts  of  glycerine  lo- 
cally to  ease  pain.  Potassium  chlorate  half  to  one  ounce  of  a  saturated  solution 


CLINICAL    INDEX.  659 

with  ten  drops  of  laudanum  as  injection  to  inflamed  piles.  Carbolic  acid  six 
grains,  cocaine  ten  grains  and  glycerine  one  drachm. — M.  Sig.:  Inject  ten 
minims  into  the  tumor. 

HAY=FEVER. — Quinine  is  useful  at  the  onset  as  a  spray  locally  and  later  in  tonic 
doses.  Aconite  is  efficacious  in  the  early  stage.  Ethyl  Iodide  by  inhalation  of 
service.  Morphine  is  most  beneficial  in  any  stage.  Cocaine  to  the  nose,  as  a 
spray,  is  a  very  effective  remedy.  Potassium  iodide  ten  grains  at  bed-time 
will  often  cut  short  the  attack.  Atropine  in  doses  of  a  sixtieth  of  a  grain  when 
the  secretion  is  profuse. 

HEADACHE. — Tea  or  coffee  will  relieve  headache  from  nervousness  or  exhaus- 
tion. Belladonna  three  minims  of  the  tincture  every  three  hours,  when  pain  is 
over  brows  and  in  eyeballs.  Arsenic  in  three  drop  doses  t.  i.  d.  for  neuralgic 
headache.  Bromide  potassium  in  thirty  grain  doses  for  sick  or  nervous  head- 
ache. Sodium  phosphate  teaspoonful  t  i.  d.  in  bilious  headache.  Acetanilid 
in  five  grain  doses  every  thirty  minutes  until  relieved  or  until  three  doses  have 
been  taken. 

HEART,  DISEASES  OF.— Horphine,  hypodermically,  in  dilated  heart  and  general 
dropsy  therefrom.  Iron  is  of  great  utility  in  the  irritable  heart  of  anaemia. 
Ergot  is  useful  in  dilated  heart.  Digitalis  is  remarkably  beneficial  in  rapid  ac- 
tion with  low  tension  and  valvular  lesions.  Bromide  potassium  in  ten  grain 
doses  t.  i.  d.  is  useful  for  over-action  and  simple  hypertrophy.  Quinine  in 
tonic  doses  for  cardiac  weakness.  Atropine  is  a  prompt  cardiac  excitant. 
Acohol  in  form  of  brandy  or  wine,  when  the  heart  is  suddenly  enfeebled  by 
fright,  loss  of  blood,  accident,  etc.  Arsenic  Fowler's  sol.  in  three  drop  doses 
t.  i.  d.  after  meals,  for  breathlessness  on  exertion  from  weakly-acting  heart. 
Strychnine  in  medicinal  doses  strengthens  the  heart  beats. 

HEMIPLEGIA. — Strychnine  by  hypodermic  injections  into  the  paralyzed  muscles 
most  useful.  Massage.  Galvanism  to  brain  and  cord  and  faradism  to  the 
to  the  muscles  if  they  waste 

HEPATIC  DISEASES.— Chloride  of  gold  and  sodium  is  effective  in  sclerosis. 
Phosphate  sodium  is  one  of  the  most  useful  and  certain  cholagogues.  Am= 
monium  chloride  is  useful  in  catarrh  of  the  bile-ducts.  Rhubarb,  aloes  and 
podophyllum  are  effective.  Nitro=muriatic  acid  is  useful  in  ten  drop  doses 
t.  i.  d.  in  torpor  of  the  liver. 

HERNIA.— Chloroform  by  inhalation  to  assist  reduction. 

HERPES. — Morpha  oleate  applied  locally  in  herpes  zoster.  Iodine  liniment  ap- 
plied once.  Hot  fomentations  will  often  disperse  the  development  of  herpes 
labialis.  Calomel  and  zinc  ointments  are  curative.  Galvanism  in  cases  of 
herpes  zoster. 

HICCOUGH. — Morphia  grs.  %  hypodermically.  Apomorphia  gr.  TV,  hypoder- 
mically, will  sometimes  cure.  Mustard  one  drachm  infused  in  four  ounces  of 
boiling  water  has  cured  obstinate  cases. 

HOARSENESS.— Turkish  bath  at  the  onset  will  cut  it  short.  Borax  the  size  of  a 
pea  dissolved  in  the  mouth.  Ipecac  wine  as  a  spray  to  throat.  Alum  as  a 
spray,  ten  grains  to  an  ounce  of  water.  Nitric  acid  is  highly  effective  in 
hoarseness  of  singers  and  reflex  from  the  stomach  in  ten  minim  doses  of  the 
dilute  acid.     Atropine  in  hysterical  aphonia. 

HYDROCELE. — Iodine  tinct.  injected  into  the  sac  after  removal  of  the  fluid. 
Carbolic  acid  and  nitrate  silver  a  strong  solution  injected  in  the  same  way. 

HYPOCHONDRIASIS Patassium  bromide  fifteen  grains  t.  i.  d.  Gold  and  sodium 

chloride  in  gr.  xWV  doses 't.  i.  d.  gives  excellent  results  in  the  hypochondria 
of  the  aged.  Laudanum  in  small  doses  is  a  remedy  of  the  first  importance. 
Arsenic  gives  good  results  in  the  aged.     Asafoetida  in  cases  with  flatulence. 

HYSTERIA.— Cod=liver  oil  and  the  "rest  cure  "  are  useful.  Aconite  tinct.  for  flut- 
tering of  the  heart  in  nervous  persons.  Potassium  bromide  in  large  doses  pre- 
vents paroxysms.  Opium,  a  drop  of  laudanum  with  two  of  the  tinct.  of  nux 
vomica  four  times  daily  for  weight  on  head  and  flushings.     Valerian  useful 

IMPETIGO. — Quinia  in  tonic  doses  very  efficient.  Mineral  acids  in  cases  of  indi- 
gestion. Zinc  ointment  applied  relieves.  Sulphur  internally  is  of  service. 
Poultices  may  be  applied  at  night  to  remove  scabs.  Glycerine  of  tannin  is  a 
good  application.     Sugar  of  lead  in  solution  may  be  applied. 

IMPOTENCE. — Strychnia  in  large  doses  sometimes  useful  when  spermatorrhoea  ex- 
ists.    Cantharides  tinct.  in  twenty  to  thirty  drops  t.  i.   d.   with  iron  and  nux 


660  A    COMPENDIUM    OF    PRACTICAL     MEDICH5TE. 

vomica  very  useful.  Cannabis  indica  and  phosphide  of  zinc  stimulate  the  func- 
tion. Ergotine  a  hypodermic  injection  about  the  dorsal  vein  of  the  penis. 
Ergot  by  the  stomach  increases  the  vigor  of  the  erections.  Gold  and  sodium 
chloride  increase  sexual  activity  in  gr.  ^  t.  i .  d. 

INCONTINENCE  OF  URINE.— Belladonna  tinct.  ten  to  twenty  drops  t.  i.  d.  is  the 
best  remedy  for  children.  The  child  should  be  waked  at  midnight  to  pass 
water.  Ergot  said  to  be  useful  when  due  to  paresis  of  bladder. _  Iron  syrup  of 
the  iodide  in  ten  drop  doses  t.  i.  d.  in  anaemic  subjects.  Collodion  painted  to 
form  a  cap  over  end  of  prepuce.  Chloral  is  sometimes  effective  in  children. 
Strychnia  good  in  old  people  with  paralysis  of  the  bladder.  Cantharides 
tinct.  two  drops  t.  i.  d. 

INDIGESTION.— Acid  hydrochloric  ten  minims  t.  i.  d.  of  the  diluted  acid.  Lactic 
acid  good  in  atonic  dyspepsia  and  indigestion.  Alcohol  in  small  doses  is  an  ex- 
cellent stomachic  tonic.  Bismuth  for  painful  indigestion  and  nausea.  Aloes 
in  indigestion  with  torpor  of  large  intestine  and  pasty  motion. 

INSOMNIA. — Potassium  bromide  in  thirty  grain  doses  at  bed-hour.  Paraldehyde 
thirty  to  fifty  minims  is  said  to  be  very  effective.  Chloral  is  the  most  direct 
and  generally  useful  hypnotic  in  fifteen  to  twenty  grain  doses  at  bed-time. 
florphine  and  atropine  hypodermically  is  the  best  sleep  producer  in  cases  of 
pain,  mania,  and  melancholia.  Alcohol  is  efficient  when  due  to  cerebral 
anaemia.     Warm  bath  at  bed- hour  often  succeeds. 

INTERTRIGO.— Bismuth  subnitrate  dusted  over  the  surface.  Tannin  in  powder  is 
a  useful  application.     Zinc  ointment  is  very  efficient  in  some  cases. 

INTESTINAL  CATARRH. — Ammonium  chloride  five  grains  t.  i.  d.  is  a  valuable 
remedy.  Salol  is  a  useful  drug  into  three  to  five  grain  doses  t.  i.  d.  after 
meals.  Bismuth  is  one  of  the  best  remedies.  Calomel  in  minute  doses  fre- 
quently is  of  great  service.     Hydrastis  is  a  useful  drug  in  this  condition. 

IRITIS. — Atropine  two  to  four  grains  to  the  ounce,  a  drop  or  two  in  the  eye,  four 
to  six  times  daily  to  prevent  adhesions.  Eserine  to  break  up  adhesion  and  di- 
minish intra-ocular  tension.     Mercury  in  specific  iritis. 

JAUNDICE. — Mercury,  in  form  of  gray  powder,  gr.  |  four  times  daily  at  the  onset, 
is  very  valuable.  Calomel  in  small  doses  gives  good  results.  Benzoic  acid,  to 
remove  bile  from  the  system.  Sodium  phosphate,  a  teaspoonful  t.  i.  d.  very 
useful.  Skim=milk  cure.  Ammonium  chloride  gr.  v.  t.  V.  d.  is  beneficial. 
Nitro= muriatic  acid  dil.  in  ten  minim  doses  t.  i.  d.  Rhubarb,  aloes  and  podo= 
phyllum  are  excellent  remedies  in  this  condition. 

JOINTS,  DISEASES  OF. — Blisters,  a  succession  of  them  about  the  joints,  in  cases 
of  synovitis.  Nitrate  silver,  grs.  xx.  to  an  ounce  of  nitrous  ether,  is  an  efficient 
application  to  check  inflammation.  Oleate  of  mercury  and  morphine  rubbed 
into  the  joint  is  of  great  service  in  inflammatory  affections  of  joints.  Galvan= 
ism  and  massage  are  highly  useful. 

LACTATION. — Atropine,  four  grains  to  the  ounce  of  rose  water,  applied  on  lint  to 
the  gland  to  arrest  secretion.  Phosphate  of  lime  is  highly  useful  in  the  debility 
of  lactation. 

LARYNGITIS.— Aconite  tinct.  in  small  doses  frequently.  Tannin  and  glycerine 
applied  to  the  throat. 

LEUCORRHOHA. — Bicarbonate  of  potash,  or  soda  one  drachm  to  a  pint  of  water 
when  discharge  is  alkaline.  Carbolic  acid,  one  drachm  to  a  quart  of  water. 
Alum,  one  drachm  to  a  pint  of  water,  is  a  useful  injection.  Zinc  sulphate  may 
be  used  also.  Iodoform  and  tannin  packed  about  the  cervix  is  highly  useful. 
Acetate  of  lead  properly  diluted  is  an  excellent  local  application.  Bismuth 
may  be  combined  with  fluid  extract  of  hydrastis. 

LICE. — Bichloride  of  mercury  solution  destroys  lice  on  all  parts  of  the  body.  All 
the  essential  oils  will  destroy  lice. 

LUMBAGO. — Chloroform,  a  few  drops  injected  deeply,  is  remarkably  beneficial. 
Galvanism  usually  effects  a  cure.  Faradism  is  sometimes  useful.  Morphine, 
hypodermically,  affords  prompt  relief.  Heat  to  the  back  for  three  hours. 
Massage  is  curative  in  some  cases. 

MENORRHAGIA. — Ergot  is  very  useful  in  all  forms.  Gallic  acid  sometimes  suc- 
ceeds well.  Potassium  bromide  in  fifteen  to  thirty  grain  doses  t.  i.  d.  often 
arrests  promptly.  Cinnamon,  the  oil  in  drachm  doses  given  several  times 
daily,  is  highly  recommended. 


CLINICAL    INDEX.  661 

MYALGIA.— Massage  will  usually  do  good.  Galvanism  will  surely  cure.  Faradism 
may  succeed.  Acetanilid  is  an  efficient  remedy.  Laudanum,  applied  with 
friction,  gives  relief. 

NEURALGIA.— Morphine,  hypodermically,  is  the  most  efficient  remedy  for  the 
relief  of  pain.  Galvanism  is  the  most  decidedly  curative  agent.  Hassage  gives 
much  relief.  Iron,  for  the  existing  anaemia.  Bromide  potassium  is  useful  in 
some  cases.  Arsenic  will  benefit  some  cases.  Strychnine  long  continued  in 
depressed  states  of  the  nervous  system.  Anaesthetics  promptly  relieve.  Ace- 
tanilid  will  relieve  in  some  cases. 

OBESITY.— Acids,  alkalies,  bromides  and  potassium  permanganate  will  promote 
destructive  metamorphosis. 

ORCHITIS.— Mercury,  the  oleate  painted  over.  Ice  in  a  bag  kept  applied.  Iodine 
tinct.  locally  applied.     Nitrate  of  silver  in  nitrous  ether  painted  over. 

PARALYSIS.— Strychnine,  injected  into  the  muscular  substance,  is  of  the  greatest 
utility  in  all  forms  of  paralysis,  but  must  be  used  after  local  trouble  in  the 
nerve-centers  have  subsided.  Phosphorus  should  be  given  to  restore  nerve- 
matter,  and  in  hysterical  paralysis.  Cod=liver  oil  is  useful  to  restore  nervous 
matter.  Ergot  is  useful  in  some  cases.  Iodide  of  potassium  in  paralysis  due 
to  gumma.  Galvanism  and  faradism  are  first  in  importance  in  the  treatment 
of  paralysis.     Massage  is  an  important  adjunct  to  other  kinds  of  treatment. 

PEMPHIGUS.— Arsenic,  Fowler's  sol.,  five  drops  t.  i.  d.  after  meals,  for  chronic 
form.     Belladonna  tinct.,  five  minims  t.  i.  d.  for  the  acute. 

PERITONITIS. — Morphine,  hypodermically,  is  the  most  efficient  drug.  Must  be 
given  freely.  Quinine  in  full  closes  at  the  onset.  Turpentine  when  there  is 
tympanites,  especially  useful  in  puerperal  peritonitis.  Aconite  for  the  fever  at 
onset.    Locally,  ice-bag  to  abdomen;  counter-irritation;  heat;  poultices;  leeches. 

PERSPIRATION,  EXCESSIVE.— Belladonna,  as  a  liniment,  locally  to  the  affected 
part,  and  tinct.  internally.  Ergot  is  said  to  arrest  sweating.  Picrotoxin,  a 
minute  dose,  will  stop  for  several  nights  the  sweats  of  consumption.  Atropine 
for  "  night-sweats."  Pilocarpine  in  ^  grain  doses  thrice  daily.  Oxide  of  zinc 
in  two  grain  doses  nightly  to  control  profuse  colliquative  sweating. 

PHARYNGITIS. — Silver  nitrate  two  grains  to  the  ounce  of  water  is  effective  in 
many  cases.  Tannin  locally,  in  powder  or  solution.  Hydrastis  is  an  excellent 
topical  application.  It  may  be  taken  internally  in  doses  of  five  to  ten  drops 
t.  i.  d. 

SALIVATION.— Alcohol  diluted  as  a  gargle.  Iodine  two  drachms  of  the  tincture 
to  eight  ounces  of  water.  Acids  in  small  medicinal  doses  as  astringents.  Bro- 
mide of  potassium  very  beneficial  in  salivation  of  pregnancy. 

SCABIES.— Carbolic  acid  locally  to  destroy  the  parasite.  Sulphur  after  a  warm 
bath  with  soap  and  water,  rub  in  ointment  composed  of  two  parts  of  sulphur, 
one  of  carbonate  of  potash  and  eight  of  lard.  Clothing,  submit  all  clothing 
which  cannot  be  boiled  to  a  temperature  between  250°  and  300°.  Sulphate  of 
copper  used  as  a  lotion  is  successful. 

SCIATICA.— Methylal  a  twenty  per  cent,  mixture  with  oil,  rubbed  in  along  the 
nerve  is  effective.  Morphine  hypodermically.  Chloroform  and  ether  injected 
deeply  in  old  cases  is  beneficial.  Poultices  applied  very  hot.  Galvanism  very 
effective.  Nitrate  of  silver  inject  ten  to  twenty  drops  of  the  solution  deeply 
near  the  affected  nerve.     Aquapuncture  is  much  used  recently. 

SCLERODERHA Cod=liver  oil   an   important  remedy.     Galvanism   (central)    is 

recommended.     Phosphates  and  hypophosphites  with  or  without   cod-liver  oil. 

SCROFULA.— Calomel  ointment  to  sores  The  Phosphates  are  very  beneficial  to  im- 
prove the  nutrition.  Iron  long  continued  is  useful.  Tinct.  of  iodine  applied  over 
scrofulous  glands.  Cod-liver  oil  is  of  great  service.  Chloride  of  calcium  in  ten 
to  twenty  grain  doses  in  milk  after  food  is  effectual  in  enlarged  glands  and 
chronic  diarrhoea. 

SEA-SICKNESS.— Chloral  fifteen  to  thirty  grains  every  four  hours.  Spinal  ice- 
bag  sometimes  of  service.  Nitro  glycerine  has  been  recommended.  Chloro- 
form  one  drop  by  the  stomach  frequently  repeated.  Bromide  of  soda  one-half 
to  one  drachm  taken  before  embarking  is  the  best  remedy.  Morphine  in  small 
doses  hypodermically.  Nitrite  of  amyl  inhaled  for  prevention.  Nitro-glycer- 
ine  by  the  stomach  is  useful. 

SLEEPLESSNESS.— (See  Insomnia). 


662  A    COMPENDIUM    OF    PRACTICAL     MEDICINE. 

SNEEZING. — Iodine  inhalations  in  sneezing  with  itching  of  nose.     Camphor  inhal- 

tions  or  the   powder  sniffed  up  the   nose   is  useful   in  sneezing-   with   running 

from  nose  and  eyes.     Arsenic  one   drop   of   the   liquor   three  times   a   day   in 

sneezing  of  asthma      Iodide  of  potassium  ten  grains  several  times  daily. 

SORE-FEET. — Washing  soda,  one  tablespoonful  to  one-half  gallon  of  warm  water 

as  foot-bath. 
SORES. — Alum  in  powdered  form  to  secreting  sores.     Iodoform  is  good  used  as  a 
dusting  powder  over  all  forms  of  sores.     Opium  and  glycerine  as  an  applica- 
tion for  pain.     Sulphate  of  zinc  is  applied  locally  to  sloughing  sores  with  bene- 
fit.    Carbolic  acid,  boracic  acid   and  salicylic  acid  are  applications  of  great 
value  as  antiseptics,  deodorants  and  alteratives.     Potassa  chlorate   in  powder 
is  remarkably  beneficial.     Camphor  as  a  dusting  powder  is  effective. 
SPERMATORRHOEA.— Nux  vomica  is  useful  as  a  tonic.    The  tincture  of  the 
chloride  of  iron  and  arsenic  are  remedies  of  value  when   anaemia   is   present. 
Belladonna,  one-fourth  grain  of  the  extract  with  one  and   one-half   grains  of 
zinc  sulphate  three  times  a  day  is  often  of  use.     Camphor  in  large  doses  may 
be  used  with  benefit. 
SPRAIN.— Cold  douche  with  salt  added  is  beneficial  to  relieve  stiffness. 
STINGS. — Weak  solutions  of  ammonia  are  effective. 

SUN=STROKE. — Cold  douche  when  patient  is  struck  down  unconscious. 
SWEATING. — Atropine  is  very  efficacious  in  sweating  of  phthisis,  one-sixtieth  of 
a  grain  at  bed-time.  Oxide  of  zinc  is  very  effective  in  night-sweats  of  phthisis. 
Oxide  of  zinc  three   grains   and   one-half   grain  of  belladonna,    given  at  bed- 
time.    Picrotoxin  from  one  hundred  and  eightieth  to  one-sixtieth   of   a  grain, 
has  been  very  successful.     Pilocarpine  in  one-twentieth  of  a  grain  doses  thrice 
daily,  is  often  useful.     Sponging  with  acidulated  water,  often  effective. 
SYNOVITIS. — Blisters  every  night  are  useful.     Cod=liver  oil  is  useful  if  patient  is 
debilitated.     Iodine,  applied  to  joint  in  chronic  cases,     flassage  may  be  tried. 
Nitrate  of  silver  in  nitrous  ether  may  be  applied  to  the  joint.     Mercury  and 
Morphia,  oleate  of,  applied  locally. 
TETANUS. — Bromide  of  potassium  in  large  doses,  one  drachm  every  three  or  four 
hours  is  a  remedy  of  great  value.     Morphine  injected  into  the  affected  muscles 
gives  relief.     Paraldehyde  given  in  sufficient  quantity  has  often  proved  suc- 
cessful.    The  maximum  dose  (two  and  one-half  drachms)  has  been  given  with- 
out ill  effect.     Chloral  in  large  doses  is  of  great  value.     Ether  spray  to  spine 
every  two  hours. 
THIRST. — Hot  drinks  are  of  service.     Ice,  allowed  to  melt  in  the  mouth,  is  useful. 

Acid  drinks  are  effective  to  allay  thirst  in  fevers. 
THRUSH. — Boracic  acid  solution  mixed  with    honey  (|)  is  very  useful.     Sulphur= 
ous  acid  solution,  strong  or  diluted,   applied  locally.     Salicylic  acid,  one  part 
(dissolved  in  alcohol)  to  250  of  water. 
TOE  NAIL,  INGROWING. — Liquor  potassaj,  two  drachms  to  the  ounce  of  water. 
A  piece  of  cotton  saturated  with  the  solution  is  pressed  under  the  ingrowing 
nail,  repeated  each  morning;  the  nail  becomes  thin  and  can  be  pared  away 
without  pain. 
TOOTHACHE.— Opium  or  morphine   (solution)    dropped    in    the    cavity.     Oil  of 
.     cloves,  carbolic  acid  or  resorcin  in  the  decayed  tooth  are  effective.     Carbonate 

of  soda  (a  saturated  solution)  held  in  the  mouth  stops  the  pain. 
ULCERS.— See  Sores. 
URTICARIA.— Chloroform  ointment  for  the  itching.   Nitric  acid,  diluted,  as  a  wash 

for  itching.  Alkaline  washes  should  be  used.  Warm  baths. 
VOMITING. — Alum  in  six  to  ten  grain  doses  in  obstinate  vomiting  of  phthisical 
patients.  Nux  vomica  and  ipecac  are  useful  when  tongue  is  coated,  riorphine 
hypodermically.  Mercury  as  gray  powder,  one-third  of  a  grain  every  two 
hours.  Lime  water  and  milk  in  vomiting  of  infants.  Chloroform,  in  drop 
doses.  Bismuth,  ten  to  fifteen  grain?  every  two  hours,  very  effective  in  vomit- 
ing caused  by  gastric  disturbance.  Champagne  or  brandy,  iced,  in  small  doses 
frequently  repeated,  often  useful. 
VULVITIS.— Lime  water,  locally.   Alum,  sixty  grains  to  a  pint  of  water,  every  two 

hours,  as  injection.     Glycerine  of  Tannin  can  be  used  with  advantage. 
WARTS. — Mercury,    nitrate    of,    locally    applied.     Arsenious    acid    as    caustic. 
Chromic  acid,  a  solution  of  100  grs.  to  the  oz.  applied  carefully  with  a  glass  rod 


CLINICAL    INDEX.  663 

to  growth;  dress  with  dry  lint.  Nitric  acid  one  drachm  or  two  of  the  dil.  acid 
to  a  pint  of  water,  as  wash  to  keep  warts  constantly  moist. 

WHOOPINQ=COUQH.— Belladonna,  ten  minims  of  tinct.  each  hour,  to  child  three 
years  old,  especially  during-  third  week  if  no  complications.  Chloroform  or 
ether  to  lessen  violence  of  paroxysms.  Carbolic  acid  inhalations  are  some- 
times useful.     Castanea,  fluid  extract  in  doses  of  one  drachm  t.  i.  d. 

WORMS. — Iron,  tincture  of  the  chloride,  one-half  ounce  in  a  pint  of  water,  a  good 
injection  for  thread  worms,  coagulating  the  albumen.  Common  salt,  weak 
solution  injected  into  the  rectum  for  thread  worms.  Potassium  bromide,  five 
grain  doses,  t.  i.  d.,  in  convulsions  caused  by  worms.  Areca  nut,  a  half  or 
Whole  nut  is  to  be  powdered  and  mixed  with  some  syrup  and  swallowed  for  tape- 
worm. Chloroform  in  drachm  doses  taken  in  the  morning,  fasting,  for  tape- 
worm. Lime  water  injection  for  thread  worms.  Santonin,  five  grains  for 
adults  at  bed-time  for  round  worm.  Turpentine  as  a  poison  to  tape  and  thread 
worms. 


RBB  BIUU. 


Administration  of  aneesthetics $    5  to  §  10 

Consultation  visits S  to  SO 

Examination  for  life  insurance 3  to  10 

Office  prescription- .. .50  to  2 

Expert     testimony      (medico-legal) 

per  day. - -. 10  to  50 

Thorough  examination  in  office 5  to  10 

Microscopical  examination  of  urine.      2  to  10 

Urine  tested  chemically 2  to  10 

Day  visit  in  city 1.50  to  3 

Night  visit  in  city . 2  to  5 

Country  visits,  extra  per  mile 1 

Vaccination --    .50  to  1 

Visit  in  case  of  poisoning _ 5  to  10 

GENITO  URINARY  AND  VEN- 
EREAL DISEASES. 

Gonorrhoea  (in  advance) $  15  to  $  20 

Syphilis  (in  advance) - 25  to  100 

Sounding  for  stone  in  bladder 10  to  20 

Removing  stone  in  bladder 50  to  200 

External  urethrotomy -.- 50  to  250 

Internal  urethrotomy 25  to  75 

Urinary  fistula 50  to  100 

Aspirating  the  bladder 20  to  50 

Circumcision -  25  to  50 

Varicocele 20  to  75 

Tapping  of  hydrocele 10  to  15 

Radical  cure  of  hydrocele 25  to  75 

Phimosis  or  paraphimosis .  10  to  25 

OBSTETRICS  AND  GYNECOLOGY. 

Labor,  ordinary  cases ..$  10  to  3  30 

Abortions 10  to  50 

Instrumental  delivery,  additional.--  10  to  15 

Delivery  of  placenta 5  to  10 

Consultation 10  to  15 

Embryotomy __.  25  to  50 

Perineorrhaphv  (primary) 10  to  30 

Perineorrhaphy  (late). 25  to  100 

Laparotomy. 50  to  200 

Ovariotomy 50  to  200 

Hysterectomy 150  to  500 

Hysterorrhaphy.. 100  to  300 

Amputation  of  cervix 50  to  100 

Colporrhaphv 50  to  100 

Trachelorrhaphy.. 50  to  100 

Alexander's  operation 50  to  150 

Curetting 25  to  75 

Removal  of  polypi 25  to  75 

Removal  of  tumors  of  labia .  20  to  50 

Removal  of  urethral  caruncle 25  to  100 

Colpocleisis - 50  to  150 

Examination  by  speculum 5  to  10 

Endocervicitis,  operation  for.. 25  to  50 

Intrauterine  douche 5  to  15 

Fitting  of  pessary 5  to  15 

Replacement  of  uterus 5  to  15 

Vesico-vaginal  fissure,  operation  for  50  to  100 

Dilation  of  cervix  in  stenosis 15  to  25 

Atresia  of  vagina,  operation  for 50  to  150 

OPERATIVE  SURGERY. 

Laparotomy $  75  to  $200 

Hemorrhoids,  internal 25  to  75 

Hemorrhoids,  external 10  to  50 

Hare-lip... 25  to  100 

Excision  of  mammary  gland 50  to  100 

Trephining 100  to  200 

Removing  large  tumors 100  to  300 

Removing  small  tumors 30  to  100 

Staphylorrhaphy 50  to  100 

Nephrectomy 100  to  250 

Necrosis  Ol  bone 25  to  50 

Fistula  in  ano 25  to  50 

Radical  cure  of  hernia ....  100  to  150 

Strangulated  hernia 100  to  200 

Strangulated    hernia    (reduced    by 

taxis).. 25to  50 

Polypus  of  rectum 25  to  50 

Anal  fissure 25  to  50 

Hernia  (Warren's  operation) 25  to  75 

Varicose  veins  (radical  cure) 25  to  50 

Aspiration  of  joints... 25  to  40 

Selecting  and  adjusting  truss 5  to  10 


AMPUTATIONS. 

Knee $  50  to  $200 

Hip-joint.. lOOto  200 

Leg 50to  i50 

Foot _ 50  to  75 

Toes... 25  to  50 

Thigh lOOto  150 

Shoulder-joint -. 100  to  150 

Arm --_ _.     50to  100 

Hand 40  to  75 

Finger... 15  to  30 

DISLOCATIONS. 

Shoulder ...$  50  to  $  75 

Hip, 50to  100 

Knee 25  to  75 

Ankle... 25  to  50 

Arm.. _ 25  to  50 

Maxillary  bones.. 25  to  50 

Wrist... 25  to  40 

Toes... - lOto  25 

Fingers 10  to  25 

FRACTURES. 

Scapula S  25  to  $  50 

Femur 50  to  100 

Fibula 25to  50 

Leg  (both  bones) 50  to  75 

Ribs.... 25to  50 

Humerus 25  to  50 

Radius  or  ulna 25  to  50 

Elbow-joint '. ., 25  to  50 

Nose 25to  60 

Smallbones - 10  to  25 

Forearm  (both  bones) 50  to  »75 

Coracoid  or  coronoid  process 25  to  50 

^Clavicle - 50  to  75 

RESECTIONS. 

Ankle-joint  or  foot S  50  to  S  75 

Elbow $  50to  75 

Femur  (head  of)... 100  to  200 

Knee 75  to  100 

Shoulder 75  to  100 

Maxilla 50  to  100 

Ribs 25to  50 

LIGATIONS. 

Brachial  artery $  50  to  $  75 

Subclavian  or  iliac  artery 100  to    200 

Axillary,  femoral,  carotid,  popliteal 

or  poterior  tibial  artery _.. 50  to    100 

All  other  arteries - 20  to      40 

EYE. 

Sclerotomy S  50  to  $100 

Strabismus  (each  eye) 40  to  100 

Trachoma  (each  eye)..- 50  to  100 

Canthotomy  (each  eye) 40  to  75 

Opening  lachrymal  duct 25  to  50 

Cataract 100  to  250 

Artificial  pupil  (operation  for} 50  to  100 

Pterygium  (each  eye) 50  to  100 

Tumor  of  lids 25  to  75 

Enucleation - 100  to  200 

Astigmatism .     25  to  50 

Glass  fitting 10  to  20 

EAR. 

Polypus,  removal  of -.. --$  50  to  $  75 

Foreign  bodies,  removal  of 10  to      40 

Opening  of  mastoid  bone 100  to    200 

NOSE,  THROAT  AND  CHEST." 

Nasal  tumors 5  25  to  $  75 

Deflected  septum 50  to  100 

Tonsil,  excision  of 25  to  75 

Uvula,  excision  of 25  to  50 

Tracheotomy 100  to  200 

Laryngeal  tumors 50  to  200 

Adenoid  vegetations 25  to  ?5 

Larynx,  intubation  of 50  to  100 

Lungs,  thorough  examination  of    ..      5  to  10 


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